Unlicensed Staff Directed to Administer Medications During Nurse–Resident Conflict
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were administered by a licensed nurse in accordance with the resident’s plan of care and facility policy. The facility’s medication administration policy states that only persons licensed or permitted by the state may prepare, administer, and document the administration of medications. A grievance filed by Resident R1 indicated that a licensed nurse (Employee E4) did not personally give the resident their medications. The grievance documentation showed that Employee E4 reported the resident would not accept medications from them, and the Medication Administration Audit Report reflected that Employee E4 was removed from Resident R1’s nursing unit on February 21, 2026. Resident R1 reported an ongoing conflict with Employee E4 and stated that the nurse gave the resident’s medications to a nurse aide to hand to the resident because they were not getting along. In a telephone interview, Employee E4 confirmed instructing a nurse aide to administer medications to Resident R1, stating that the nurse remained nearby while the aide handed the medications to the resident. Employee E4 also stated they did not know the name of the nurse aide involved. Resident R1 similarly did not recall the aide’s name and expressed not wanting the aide to get in trouble. These findings show that an unlicensed nurse aide was directed to administer medications, contrary to the facility’s policy and state requirements that only licensed or permitted personnel may perform this task.
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