Failure to Administer Prescribed Medications Due to Inadequate Shift Handover
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses administered medications as prescribed to three residents. Specifically, a review of clinical records and staff interviews revealed that three residents did not receive their scheduled medications on a particular day. One resident with dementia and bipolar disorder did not receive a prescribed dose of oxycodone for back pain, while two other residents, one with neuropathy and depression and another with COPD and a hip fracture, did not receive their scheduled doses of gabapentin for neuropathy. The missed medication administrations were linked to a breakdown in staff coverage and communication during a shift change. One LPN left her assignment early due to a family emergency and handed over her responsibilities to another LPN. The incoming LPN, who had been assisting on other units, did not verify that all medications and treatments had been provided before the end of her shift. As a result, the scheduled medications for the three residents were not administered at the prescribed time. Documentation and interviews confirmed that the nurses involved did not ensure the completion of medication administration or maintain accurate records as required by facility policy and state regulations. The facility's own investigation found that the handoff between staff was incomplete, and alternative coverage was not secured, directly resulting in the missed medication doses for the affected residents.