Failure to Follow Medication Administration Policy and Incomplete Controlled Drug Inventory Documentation
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow the facility's medication administration policies by crushing and administering Metoprolol Extended Release (ER) to a resident with diagnoses of anemia, hypertension, and multiple sclerosis. During medication administration observation, the LVN prepared and crushed all of the resident's medications, including Metoprolol ER, and administered them. Upon review, the LVN acknowledged that Metoprolol ER should not have been crushed, as confirmed by the facility's policy, which states that medications should only be crushed when appropriate and safe, and that long-acting medications should not be crushed. Additionally, the facility failed to maintain accurate controlled drug inventory records for two medication carts on one unit. Controlled Drug Inventory (CDI) forms for multiple shifts were missing required signatures from both off-going and oncoming nurses, as observed and confirmed by staff. The facility's job description for charge nurses requires accurate narcotic records for each shift, but this was not followed, as acknowledged by the Director of Nursing.