Failure to Follow Syringe Driver Medication Preparation Standards
Penalty
Summary
A contracted LPN failed to follow professional standards of practice when preparing a physician-ordered medication for a resident receiving hospice services via a syringe driver. The LPN did not add the required distilled water to the medication mixture, as specified in the facility's syringe driver procedure. This omission was discovered when the oncoming nurse identified an incorrect controlled medication count for morphine during a shift change. The LPN later confirmed in an interview that she had not added the distilled water as instructed. The resident involved was admitted to the facility and was receiving continuous medication through a syringe driver for pain, anxiety, and agitation. The facility's policy required staff to follow a specific procedure for preparing medications for the syringe driver, including the addition of sterile water. While regular staff received training on the use of syringe drivers, travel staff, such as the LPN involved, did not receive this training prior to working shifts and were expected to be educated by their employment agency. The facility's medication administration policy also instructed staff to seek clarification if unfamiliar with a medication or procedure.