Failure to Ensure Safe and Accurate Medication Administration
Penalty
Summary
Two residents experienced deficiencies in the administration of medications as prescribed. One resident, with diagnoses including type 2 diabetes, morbid obesity, and chronic kidney disease, had an order for Ozempic to be administered subcutaneously once weekly. On one occasion, a registered nurse observed medication leaking from the injection site and attempted to compensate by administering an additional amount, but did not document the altered dose or notify the provider or facility administration. On a subsequent occasion, another nurse did not have the medication available to administer, yet the medication administration record incorrectly indicated that the dose had been given. The nurse verbally communicated the missed dose, but the documentation did not reflect the actual event, leading to inaccurate records regarding medication administration. Another resident, with diagnoses including diabetes and severely impaired cognition, had an order for sliding scale Lispro insulin to be administered subcutaneously three times daily. During an observed medication pass, a registered nurse administered the insulin using an injectable pen but did not hold the pen to the resident's skin for the recommended duration, removing it in less than two seconds instead of the required five to ten seconds. This action was inconsistent with the facility's policy and the manufacturer's instructions for proper insulin pen use. These events were identified through observation, staff interviews, and record review, revealing failures to follow established medication administration protocols, accurately document medication administration, and ensure that medications were administered as ordered for both residents.