Failure to Follow Professional Standards in Medication Administration and Documentation
Penalty
Summary
Facility staff failed to adhere to professional standards of practice in two separate cases involving medication administration and documentation. In the first case, a licensed practical nurse (LPN) administered an incorrect dosage of Folic Acid to a resident. The physician's order specified a 1 mg dose, but the LPN used a 400 mcg tablet from house stock and attempted to approximate the correct dose by dividing the tablet, which did not match the prescribed amount. The LPN acknowledged the difficulty in using stock medications and calculating dosages, and facility policy required strict adherence to the '5 Rights' of medication administration, which was not followed in this instance. In the second case, staff failed to document significant behavioral events, a change in condition, and a resident-initiated hospital transfer. The resident exhibited behavioral disturbances, including yelling, confusion, and an altercation with staff, which escalated to the resident calling 911 and being transferred to the hospital. Despite these events, there was a lack of documentation in the medical record regarding the incident, the change in condition, and the transfer. Staff interviews confirmed that such incidents should be documented and that the physician and responsible party should be notified, but this was not done. Additionally, there was a failure to clarify physician orders for insulin administration for the same resident. The resident had overlapping orders for two types of insulin with similar sliding scale instructions. The electronic medication administration record showed that one insulin was not administered for several days while staff awaited clarification, but there was no evidence that clarification was obtained in a timely manner. This resulted in missed doses and a lack of adherence to prescribed treatment.