Medication Reordering and Storage Deficiency
Penalty
Summary
The facility failed to properly reorder and store medications for two residents, leading to a deficiency in medication management. Resident R72, who had a history of falls, a fracture of the left femur, and was undergoing aftercare for joint replacement therapy, had a physician's order for Oxycodone 5 mg every 6 hours as needed for pain. However, during a medication pass observation, it was discovered that there was no medication card available in the cart to fulfill this order. The last administration of the medication was recorded on 11/04/24, and the order was not resubmitted to the pharmacy, resulting in the medication being unavailable when requested by the resident. Similarly, Resident R73, who had diagnoses including Type 2 Diabetes, depression, heart failure, and a history of cerebral infarction, had a physician's order for Furosemide 20 mg daily. During a medication pass, it was observed that the medication cart did not contain Furosemide, and the medication had not been reordered from the pharmacy after the last dose was administered. Both the LPN and RN involved confirmed the absence of the medications and the failure to reorder them. The Director of Nursing and Nurse Supervisor also acknowledged that the medications were not reordered as required, leading to their unavailability in the medication carts for the residents.
Plan Of Correction
a. R72 was assessed for adverse effects with no concerns and scripts were obtained for reorder of medication immediately. Facility completed an initial audit of all med carts to ensure that all medications were available as ordered which includes Furosemide with no issues or concerns. b. Director of Nursing/Designee completed a whole house audit to verify all ordered meds in facility are present for like residents-any medications not present will be addressed and resident will be assessed for adverse effects and physician/resident representative will be notified. c. Director of Nursing/designee will educate licensed nursing staff on F761 and obtaining new scripts and reordering of medications when needed. d. Director of Nursing/designee will audit 2 of 4 medication carts each week to verify medications ordered by the physician were not missed on the MAR and are readily available for each resident on the unit weekly x 4 weeks and monthly x 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.