Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed in several instances involving medication administration. In one case, a resident with a history of cellulitis and peripheral venous insufficiency, who was cognitively intact according to her assessment, had acetaminophen left at her bedside by a licensed nurse without a physician's order for self-administration. The resident did not take the medication as intended, and her fever escalated, leading to her being found slumped and shivering, and subsequently transferred to the hospital with a diagnosis of fever and sepsis. The facility's policies required that self-administration be documented and approved by the care team, and that medications not be left unattended at the bedside, which was not followed in this instance. Additionally, the facility was found to have allowed the pre-preparation of medications for multiple residents. Staff interviews and record reviews revealed that medications were removed from their original packaging and placed in medication cups ahead of administration, with several cups containing unidentified medications left in the medication cart. Staff, including the Director of Staff Development and other licensed nurses, confirmed that this practice was not standard and posed a risk for medication errors, as it was unclear which medications belonged to which residents. The Director of Nursing was aware of these practices and, on at least two occasions, instructed staff to supervise the administration of these pre-prepared medications rather than discarding them and preparing new doses as per policy. Facility policies reviewed indicated that medications should be prepared and administered one resident at a time, with verification of the right resident, medication, dosage, time, and route. Medications were also required to be stored in their original containers until administration. The observed practices of leaving medications at the bedside without proper authorization and pre-preparing medications for multiple residents directly contravened these policies and increased the potential for medication errors and delays in care.