Failure to Supervise Student Nurse Leads to Medication Error
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to provide direct supervision to a student nurse (SN) during a scheduled medication pass, resulting in a significant medication error. The LVN prepared medications at the medication cart and handed a cup containing multiple tablets to the student nurse, instructing the student to administer all the medications to a specific resident. The LVN did not accompany the student nurse to the resident's bedside and did not observe the administration of the medications. The student nurse administered the medications without verifying the resident's identity or reviewing the medications with the resident, and the LVN was not present to ensure the five rights of medication administration were followed. As a result of this lack of supervision and failure to follow established medication administration protocols, the resident received medications intended for another resident, including Valsartan, multivitamin and minerals, Guaifenesin ER, Eliquis, Carvedilol, Keppra, and Magnesium Oxide. The resident did not receive his prescribed medications, which included Glipizide, Metformin, Baclofen, vitamin D, Iron, Finasteride, and Lacosamide. The error was discovered after the resident exhibited symptoms, and it was reported that the resident's wife noticed something was wrong. The resident was subsequently transferred to a general acute care hospital for evaluation, where he underwent blood tests and radiological studies. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the LVN did not follow facility policy or professional standards, which require direct supervision of student nurses and verification of resident identity using at least two identifiers. The facility's consultant pharmacist also confirmed that the five rights of medication administration were not followed, and the LVN failed to supervise the student nurse during the medication pass. The facility's policies and job descriptions require licensed nurses to provide nursing services in accordance with professional standards and to verify resident identity before administering medications.