Medication Borrowing from Another Resident's Supply
Penalty
Summary
The facility failed to adhere to professional standards of clinical practice by borrowing medication from another resident's supply. This deficiency was identified during a medication administration observation involving a registered nurse (RN#1) and Resident #122. RN#1 was observed administering medication to Resident #122 and admitted to borrowing the medication from another resident's supply because the required medication was not available in the medication cart for Resident #122. The surveyor reviewed the electronic medication administration record (EMAR) and confirmed that RN#1 had administered the borrowed medication without proper authorization. The nurse educator at the facility confirmed that nurses were not allowed to borrow medications from other residents and that the facility had a stock of over-the-counter medications available for residents with physician orders. Despite this, RN#1 did not follow the protocol of contacting the pharmacy or the physician for guidance when the medication was unavailable. Interviews with facility staff, including the nurse educator and other nursing staff, revealed a lack of clarity regarding the policy on borrowing medications. The nurse educator stated that borrowing medications could lead to medication errors and emphasized that nurses were instructed not to engage in this practice. However, there was no documented policy available at the time of the survey to reinforce this directive.
Plan Of Correction
Element 1 Upon identification of the error to resident #122 U.S. FOIA (b)(6), immediate corrective actions were implemented. The resident's condition was assessed for any adverse effects resulting from the NJ Exec Order 26.4b1 administration. The physician was notified and consulted to determine if any additional medical intervention was required. The physician initially provided a one-time order for the NJ Exec Order 26.4b1 that was applied. Additionally, the order was permanently revised to [R]. The nurse who administered the incorrect [R] was counseled and re-educated on the proper administration procedures for [R], including verifying the correct strength per the physician's order. A medication error form was completed right away, and she was successfully re-med passed by the Assistant Director of Nursing. All nurses were educated on the following: not to borrow any medications, NJ Exec Order 26.4b1 are over the counter and [R] is a prescription, and the right of medication pass (right patient, right drug, right dose, right dosage form, right route, right time). A follow-up monitoring plan was implemented to ensure the residents' comfort and safety were maintained and effective with the new order for [R]. A review of all residents receiving NJ Exec Order 26.4(b)(1) treatments, including NJ Exec Order 26.4b1, was conducted. An audit was completed ensuring all residents' [R] were in stock and had the appropriate dose in place. Element 2 All residents receiving topical analgesic treatments, including lidocaine patches, are at risk. Element 3 All nurses were educated on the proper procedure of medication administration by the Assistant Director of Nursing. RN#1 was med passed from the facility's pharmacy consultant with a 0% medication error rate on 1/24/25. A medication error form was completed right away for RN#1, and she was successfully re-med passed by the Assistant Director of Nursing. The Pharmacy consultant will continue to do their monthly unit inspections and medication passes. Element 4 Patch spot check audits will be conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance for residents who are receiving patches to ensure the right dosage was applied and available. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.