Failure to Ensure Nurse Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) was competent in medication administration upon hire, as required by facility policy. Review of the employee file showed that the LVN was hired on 5/14/2025, but the only competency checklist present was dated 9/2/2025, indicating that a medication administration competency was not completed at the time of hire. The facility's policy requires competency evaluations upon hire, annually, and as needed, specifically including medication management. Interviews with the Director of Staff Development and Assistant Director of Nursing confirmed that the medication competency should have been completed upon hire to assess the nurse's skills and address any deficiencies immediately. As a result of this lapse, a resident with diagnoses including urinary tract infection, heart failure, and major depressive disorder did not receive scheduled doses of Trazodone for three consecutive days. Review of the Medication Administration Record (MAR) for August 2025 showed no documentation of Trazodone administration on 8/23, 8/24, and 8/25, and interviews with nursing staff confirmed that the documentation was blank for those dates. The absence of documentation meant there was no proof the medication was administered, and staff acknowledged that missing doses could affect the resident's condition.