Failure to Administer Medications and Falsification of Records by LPN
Penalty
Summary
A staff member, specifically an LPN, failed to administer medications as ordered by physicians to at least three residents during a scheduled medication pass. The incident was discovered after other staff members raised concerns that the LPN had not been observed providing medication assistance during the assigned shift. Subsequent review of facility camera footage revealed that the LPN removed narcotic medications from the medication cart, handled them with bare hands, and either discarded or pocketed the medications instead of administering them to the residents. The LPN was also observed documenting in the narcotic binder and medication administration records (MAR) that the medications had been given, despite evidence to the contrary. The residents involved were all on ventilator support, had tracheostomies, and were dependent on gastrostomy tubes for medication administration due to NPO (nothing by mouth) status. Each resident had physician orders for diazepam to be administered via gastrostomy tube at specific times. The MARs and narcotic records indicated that the medications were signed out as administered by the LPN, but camera footage and staff observations confirmed that the medications were not actually given. The LPN did not follow proper medication administration procedures, including the use of medication cups and pill crushers, and failed to enter resident rooms to deliver the medications after removing them from the cart. The facility's investigation confirmed that the LPN falsified records by signing out medications that were not administered and did not adhere to infection control protocols, such as avoiding direct hand contact with medications. The incident was reported to the facility's executive leadership, and the LPN was suspended and subsequently terminated following the investigation. The facility did not file a reportable incident with the state health department, as there were no observed adverse effects to the residents involved.