Improper Pre-Setting of Medications by LPN Leads to High Medication Error Rate
Penalty
Summary
Facility B failed to ensure proper medication administration practices by allowing an LPN to pre-set medications in labeled cups for multiple residents on one hall. Observations revealed that the LPN placed six plastic cups labeled with room numbers and bed letters on top of the medication cart, each containing medications for specific residents. Review of physician orders and medication administration records showed that the LPN administered medications as indicated for several residents, but one resident did not receive a scheduled medication (Atorvastatin), resulting in a medication error rate of 55.56%. The facility's policy requires that medications be administered in a safe and timely manner, with verification of the right resident, medication, dosage, time, and route immediately before administration. During interviews, the LPN admitted to pre-setting medications and acknowledged being previously instructed by the pharmacist consultant not to do so. The DON and Administrator both confirmed that facility expectations prohibit pre-setting and labeling medication cups in advance, requiring nurses to administer medications individually per resident. The deficiency was identified through direct observation, record review, and staff interviews, confirming non-compliance with facility policy and standard medication administration procedures.