County of Wood
DISCIPLINARY ACTION FORM 

HECEIVED
3 ?3121313 2015

 

 

 

Name: Rosemary Carlson, RN Department: LTC Nursing WOODCOUNTY 


1 

 

Type of Action Taken:
Counseling Verbal Written El Suspension El Discharge
Session (Optional) Reprimand Warning Days)

Continued infractions of performance or policy may lead to additional discipline, up to and including. termination of employment.
State subject or code of conduct rule violated.
Medication Administration and Handling

Violates Norwood?s Pharmaceutical Services- Medications: Administration and Handling Policy and Procedure

Date of Violation 8/24/16 Number of prior written warnings on file 0

 

Describe in detail information you have available which supports taking the above course of action. List witnesses to incident
if possible. State what action will be taken if problem persists.

While administering medications the nurse is to perform the 6 rights, open the medications ordered, administer the medications to the
correct patient and ensure that they are taken, and then con?rm on the 6 MAR.

Rosemary was recently trained' 1n the correct procedure for medication administration by Head Nurse of the Unit.

In this instance it was noted and admitted by Rosemary that she had prepared the medications for more than one patient at a time
before administering them. A medication error occurred d/t this violation of policy.

 

State what corrective action you feel the employee may take to eliminate the above problem area.
Employee 15 to review policies violated to ensure future understanding of Norwood?s expectations.
Employee IS to perform the medication pass as it is outlined' 1n the policy and was reviewed by Head Nurse n1 order to comply with

policy and maintain safety.
Employee will complete Relias training 1n addition to having been audited by HRN on the evening of 8/24/16 directly after medication

error occurred.
Another violation of the medication administration policy may result in a written warning or termination.

Employee Comment:

 

Appeal Rights: If you feel this action violates a Wood County or departmental policy or procedure or violates a state or
federal guideline related to your work, you should consult the ?Complaint Resolution Process? policy in the Employee Policy:
Handbook, or contact Human Resources. Failure to initiate your complaint in a timely manner may result in your complaint
options being denied.

1 have received the above notification and acknowledge that I received

rains set 1101/ limit/WW a/a/t

 

 

 

 

E1 iiployee Signature Date gnpewisor Sigrid ture Date
If the above pertains to a suspension or discharge, the Department Head ga:1:1i?nm form. 8/ 
Rev? 034013 artment Head Signature Date :05?

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