Failure to Administer and Document Medications as Ordered
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (Staff #13) was observed administering medications to a resident. During the observation, the nurse gave one puff each of Fluticasone-Salmeterol and Albuterol inhalers. However, review of the medication administration record showed that Fluticasone-Salmeterol and Umeclidinium Bromide were due to be administered at that time, not Albuterol. The nurse signed off that both Fluticasone-Salmeterol and Umeclidinium Bromide had been given, despite only Fluticasone-Salmeterol and Albuterol being administered. This discrepancy was confirmed through record review and discussed with the Director of Nursing, who acknowledged the concern. The failure to administer medications as ordered and to accurately document medication administration did not meet professional standards of practice, as evidenced by the observed event and supporting documentation.