Failure to Administer and Document Medications per Professional Standards
Penalty
Summary
Facility staff failed to follow professional standards of practice in medication administration for one resident. The resident, who was admitted with end stage renal disease and was dependent on renal dialysis, had an intact cognitive status as assessed by a BIMS score of 15 out of 15. On the date in question, a nurse (Staff #22) was working their first shift as night supervisor without a preceptor and had to cover a medication cart due to another nurse calling out. Staff #22 reported not being trained on the cart and did not consider passing medications until it was too late, as the next doses were soon due. Documentation review revealed that Staff #22 signed off on the administration of multiple medications for the resident, including Dasatinib, Duloxetine, Fenofibrate, Ferrous Sulfate, Folic Acid, Pantoprazole, a multivitamin, Apixaban, and Midodrine, despite not actually administering them. This was confirmed by another staff member who observed the discrepancy and by the resident, who stated they had not received their medications during the overnight shift. The Director of Nursing confirmed that Staff #22 had documented the administration of medications that were not given.