Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to meet professional standards of practice for medication administration for five out of eight residents reviewed. During an observation, an LPN was found to have prepared multiple residents' medications in advance, placing pills for different residents into separate medicine cups, some of which were labeled with residents' initials and one that was not labeled at all. The LPN admitted to preparing the medications early to expedite administration and confirmed that staff were not supposed to pre-pour medications. The medication cups contained varying numbers of pills, and the LPN identified which cup corresponded to which resident, including one cup with no identifying initials. During a joint interview, the DON and ADON confirmed that staff were expected to prepare and administer medications to each resident immediately after preparation and that pre-pouring medications was not permitted. They acknowledged that this practice could result in medications being given to the wrong residents and could lead to medication errors. The observations and interviews confirmed that the facility did not adhere to its own policies and professional standards regarding medication administration.