Failure to Ensure Safe and Accurate Medication Administration
Penalty
Summary
The facility failed to ensure safe and accurate medication administration for four residents, as observed during a random medication pass. An LPN was seen preparing multiple residents' medications in advance by dispensing pills from medication cards into her bare hands and placing them into medication cups, which were then stacked and labeled with residents' initials. The LPN dropped a pill onto the desk, picked it up with her bare hands, and placed it back into a medication cup. The medications were prepared ahead of time for later administration, and several medication cups were missing required medications according to the residents' electronic Medication Administration Records (eMARs). Further review revealed that the LPN had not included all prescribed medications in the cups for several residents. For example, one resident's cup was missing clonidine, another was missing magnesium oxide, primidone, and sertraline, and a third was missing atorvastatin, buspirone, gabapentin, pramipexole, sertraline, and tizanidine. Additionally, a resident reported that the LPN had attempted to give him the wrong medications on two separate occasions in the dining room, which was corroborated by his sister. The LPN admitted to setting down the wrong medication cups but claimed to have caught the errors before administration. The facility's policy, revised in 2017, explicitly stated that medications should never be pre-poured, should not be touched with bare hands, and must be prepared just prior to administration. The policy also required staff to observe residents taking their medications. Despite this, the LPN pre-poured medications for multiple residents, handled pills with bare hands, and failed to ensure the correct medications were prepared and administered as ordered.