Employee
Eleanor Voss, RN
All medication administration must be charted in the electronic record at the time of administration, with the five rights verified and witnessed where required by protocol. Controlled-substance counts must be reconciled at each shift change. Accurate, contemporaneous documentation is a patient-safety requirement and a condition of licensure-aligned practice.
Two medication administrations on the 7a–7p shift were charted retroactively at end of shift rather than at the time of administration. Addressed in a documented coaching conversation.
A controlled-substance count at shift change was not reconciled and signed before leaving the unit, requiring the oncoming nurse to flag and resolve the discrepancy.
A scheduled analgesic for a post-operative patient was administered but not documented in the medication record for over four hours, creating a risk of a duplicate dose during a care handoff.
Effective immediately, all medication administration must be charted contemporaneously at the time of administration, and all controlled-substance counts must be reconciled and signed before leaving the unit at shift change, without exception. Any deviation must be self-reported to the charge nurse at the time it occurs.
Because this is the third documented incident of the same nature and follows a prior written warning, no further progressive step remains. Any further violation of the medication-administration or documentation standards described above, of any severity, will result in the termination of your employment. This notice is not a performance-improvement plan; it is a final warning that the conduct must stop immediately and permanently.