Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide medication administration that meets professional standards for five of eight sampled residents. For one resident with diabetes, staff were observed extracting insulin from an insulin lispro kwikpen using an insulin syringe, rather than the manufacturer-recommended pen needles. Multiple nursing staff confirmed this practice, citing a lack of compatible safety needles in the facility. The insulin pens used were also not properly labeled with the resident's name, dose, or route, only displaying handwritten dates and room numbers. Staff interviews revealed that this practice had been ongoing for several months, and the central supply manager had instructed staff to use insulin syringes due to supply shortages. The facility pharmacist confirmed that extracting insulin from pens with syringes is not appropriate and can damage the pen, potentially leading to dosing errors. Another resident with a prescription for a topical analgesic did not receive the medication as ordered, despite documentation indicating it had been administered. The nurse responsible stated she thought she had given the medication but had not. For a resident prescribed amlodipine for hypertension, the nurse withheld the medication due to low blood pressure, placed the tablet in an unlabelled medicine cup, and stored it in the medication cart with only a room number written on it. The nurse later administered the medication without a new physician order and could not recall if the resident's blood pressure had increased. The medication administration record did not reflect that the medication was given as ordered. Two additional residents did not receive their prescribed medications (vitron-C and Jardiance) because the medications were not available in the facility. The nurse did not notify the physician about the missed doses. The Director of Nursing confirmed that the affected residents should have received their medications as ordered and that documentation should be accurate. The DON was not aware that staff were using insulin syringes to extract insulin from pens.