Failure to Ensure Nursing Staff Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills to safely administer medications, as evidenced by an incident involving a newly graduated LPN who administered 15 units of lispro insulin to a resident with type II diabetes mellitus, instead of the prescribed 4 units. The resident's blood sugar was checked at 185, and the error was discovered after the medication was given. The resident did not experience any adverse effects during the monitoring period following the incident. Interviews revealed that the LPN was still in orientation and was supposed to be supervised by another nurse, but due to a staff call-off, she was assigned her own cart and responsibilities without documented evidence of completed orientation or skills check-off. Both the administrator and the orienting nurse confirmed that the facility did not have a formal process for documenting orientation or competency check-offs prior to allowing new nurses to work independently. Facility policies and assessments indicated that such check-offs were required, but these were not followed in practice.