Lena (not her real name) is a nurse who had gained extensive nursing experience in a number of countries before coming to live in Ireland. When she first came to this country, she worked as a care assistant. Five years later, based on her nursing qualification obtained in an EU Member State, she registered with NMBI as a general nurse and was offered a position as a staff nurse in Nursing Home X. This 21-bedded nursing home provided an extensive induction programme, covering mandatory training, general administration, documentation, health and safety topics, and duties at night.

Lena had been working in Nursing Home X for some months when the incidents referred to below occurred. These incidents occurred at night and Lena was the only nurse on night duty.

Ms A was an elderly lady with dementia and who suffered intermittently from depression. Just before the incidents occurred Ms A’s GP had prescribed an increase in her anti-psychotic and sedative medications, and had included a benzodiazepine (PRN) if Ms A was restless at night. The deputy person in charge (Nurse J) showed Lena the updated prescription and also spoke to about the changes made in the prescription sheet by the GP.

The person in charge (Nurse K) first became concerned when Ms A appeared to be drowsier than expected the day after the prescription was first issued and on the following day. She checked Ms A’s medication administration record and noted several discrepancies between the drug prescription sheet and what was recorded as having been administered. She spoke to Lena about these errors at a formal meeting and stressed that patient safety was her primary concern. Nurse K also sensed from Lena’s responses that she may not have fully understood the verbal and written instructions relating to the change in the prescription. An action plan was developed for the purpose of improving Lena’s medication management practices. This included repeating an online medication management certificate course, conducting medication rounds only when supervised by a senior member of the nursing staff, reading Nursing Home X’s medication policies and completing an English language course.

On a later occasion relating to another resident (Ms B), a discrepancy was noted between the actual available amount of a specified controlled drug in liquid form and the volume recorded as being available. It was suggested to Lena that she had spilled the liquid medication but she maintained that this was not the case.

Following this incident, the deputy person in charge (Nurse J) conducted an audit of Ms B’s medication administration records and noted some anomalies. Nurse J discovered that a medication administration record (MAR) sheet had been discarded and a replacement MAR sheet had been completed by Lena. On the replacement sheet she had written the dates and times for a number of administered medications and also signed the names of the nurses who had administered those medications. She failed to make explicit that this was a replacement sheet and to notify any other member of the nursing team of what had occurred either verbally or by means of an incident report.

Following the internal investigation Lena’s employment was terminated and a complaint was made to NMBI.

To prevent similar incidents occurring in the nursing home, Nurse K undertook to conduct weekly medication audits, provide further training in the management and documentation of medications, and to discuss medication management issues at staff meetings.

Findings of the Fitness to Practise Committee

A public inquiry lasting two days was held in 2017. Lena was present and legally represented. The Committee heard evidence from the person in charge of the nursing home, a nurse manager, a healthcare assistant and an expert nurse witness. They also reviewed documentary evidence such as duty rosters, training records, nurse signature sheets, prescription sheets, medication administration records, incident reports, disciplinary interview notes, and HIQA notification forms.

They found the following allegations were proven, namely that Lena:

• On specified date 1, failed to accurately record the dose of medication administered to Ms A at 00.30
• On specified date 1, failed to sign for medication administered to Ms A at 00.30
• On specified date 2, failed to accurately record what medication had been administered to Ms A at 03.20
• On specified date 2, failed to accurately record the dose of medication administered to Ms A at 03.20
• On specified date 2, failed to sign for medication administered to Ms A at 03.20
• On a specified date 2, administered a named sedative and a named anti-psychotic to Ms A at 07.00 when [she] knew, or ought to have known, that there was no prescription to administer such medications at this time
• On specified date 2, failed to sign for medication administered to Ms A at 07.00
• Between specified dates 3 and 4, failed to comply with standard 1.5 of the An Bord Altranais Guidance to Nurses and Midwives on Medication Management, July 2007
• On either specified date 5 or date 6, falsified the signatures of other nursing staff of Nursing Home X on a medication administration record of a patient, Ms B
• On either specified date 5 or date 6, discarded a medication administration record relating to Ms B when she knew or ought to have known that it was inappropriate to do so
• On either specified date 5 or date 6, failed to comply with standards 7.4 and/or 7.17 of the An Bord Altranais Recording Clinical Practice Guidance to Nurses and Midwives, November 2002
• On dates between specified dates 7 and 8, failed to inform the management team of Nursing Home X that [she] had damaged and discarded a medication administration record.

In the course of the evidence, concerns were raised that some of the medication incidents were linked to difficulties with Lena’s English language competence.

All the allegations above were proven as to fact and the committee also found Lena guilty of professional misconduct in relation to all of the proven allegations.

The committee recommended that conditions be attached to Lena’s registration.

Sanction

The Board considered the Fitness to Practice Committee’s report and imposed the following conditions on Lena’s registration:

That prior to returning to the practice of nursing, Lena must:

• satisfactorily complete a Medication Management Course approved by NMBI
• satisfactorily complete a course in Documenting Clinical Practice approved by NMBI
• satisfactorily pass an English language test approved by NMBI
• pay all costs associated with meeting the above conditions.

The attachment of these conditions to Lena’s registration was confirmed by the High Court.

For more information please see the Focus on Fitness to Practise Series webpage.