Failure to Ensure Staff Competency and Adherence to IV Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies and certifications to safely administer intravenous (IV) medications, and did not follow established policies and procedures for IV medication administration, physician notification, and obtaining stat orders for medication and equipment. Specifically, two of six reviewed LPNs did not have the required IV certification to administer IV medications, and four of six reviewed LPNs did not adhere to the facility's protocols for IV medication administration. This resulted in multiple missed and incorrect doses of critical antibiotics for residents requiring IV therapy. One resident, admitted with a complex medical history including subacute osteomyelitis, spina bifida occulta, hydrocephalus, paraplegia, and other significant conditions, was ordered to receive Vancomycin 1500 mg IV every eight hours for infection. The resident received an incorrect initial dose of Vancomycin and subsequently missed eight consecutive doses over several days. Documentation and interviews revealed that staff were uncertain about medication availability, IV pump functionality, and the process for obtaining stat deliveries from the pharmacy. There was a lack of timely physician notification and inadequate documentation of missed doses and provider communications. The resident developed altered mental status, which was first identified by a family member, and was later transferred to the hospital where he was diagnosed with sepsis, with hospital records noting subtherapeutic vancomycin levels and missed antibiotic doses as contributing factors. Interviews with staff, pharmacy representatives, and providers highlighted confusion regarding medication administration responsibilities, stat order procedures, and the use of available resources such as the automated medication dispensing machine and IV pumps. The DON and medical providers confirmed that they were not appropriately notified of missed medications or equipment issues. The facility's failure to ensure staff competency and adherence to medication administration protocols resulted in significant lapses in care, including missed and incorrect antibiotic doses, delayed treatment, and a subsequent hospital admission for sepsis.