Failure to Administer and Document Medications as Ordered and Monitor Lab Values Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer prescribed medications to a resident as ordered by the physician. Specifically, the LVN did not administer amiodarone and famotidine during a scheduled medication pass, despite both medications being ordered for the resident. The LVN incorrectly stated that amiodarone had already been given by the night shift and discarded the medication, while famotidine was not administered because it was not found in the medication cart. The LVN then documented in the medication administration record (MAR) that both medications had been given, even though they were not. The LVN admitted to being confused and acknowledged that the MAR was not accurate, and also failed to seek assistance from a supervisor when unsure about the medication administration process. The resident involved had multiple complex medical conditions, including metabolic encephalopathy, dysphagia, hypertensive heart disease with heart failure, anxiety disorder, depression, a cardiac pacemaker, and a gastrostomy tube. The resident was dependent on staff for all activities of daily living and required medications to be administered via the G-tube. The failure to administer and accurately document the prescribed medications was observed during a medication pass and confirmed through interviews and record reviews. Facility policy required medications to be administered as ordered and documented accurately, with any omissions or errors to be properly recorded and reported. A second deficiency was identified involving another resident who was prescribed Epogen for anemia. The facility failed to monitor the resident's hemoglobin levels prior to administering Epogen, as required by the physician's order and manufacturer guidelines. The MAR indicated that Epogen was administered on multiple occasions without any evidence that hemoglobin levels were checked beforehand. Both the registered nurse and the director of nursing confirmed that hemoglobin monitoring should have occurred weekly prior to each administration, but this was not done. The failure to monitor hemoglobin levels before administering Epogen was confirmed through interviews and record reviews.