Medication Management Deficiencies
Penalty
Summary
The facility failed to maintain accurate drug records and ensure the availability of medications for residents. During an observation of the fourth floor south medication cart, it was found that there was no documentation in the narcotic log book indicating that shift-to-shift counts were completed. The index in the narcotic log book was incomplete and did not match the individual residents' countdown records. Employee E7, a licensed nurse, confirmed these findings and stated that it was his first day at the facility as an agency nurse, and he did not receive any training regarding medication administration. Additionally, Employee E9, the unit manager, confirmed that the shift-to-shift counts and index were not completed, emphasizing the need for staff to conduct these counts to prevent potential drug diversion. Furthermore, the facility failed to ensure that medications were readily available for administration to residents. During the morning medication pass, Employee E8, a licensed nurse, was unable to administer amlodipine to Resident R132 because it was not available in the medication cart, despite being listed in the facility's emergency pharmacy medication inventory. Similarly, Employee E7 was unable to administer potassium chloride to Resident R55 due to its unavailability in the medication cart. Additionally, Resident R142 missed several doses of levetiracetam due to a back order, as noted in the medication administration records and progress notes. Employee E4, the Assistant Director of Nursing, stated that nurses should check the emergency supply or call the physician if medications are not available in the medication cart.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. The DON/designee conducted an audit of narcotic books to ensure shift to shift count is being completed and the index of the narcotic log book is complete and matches the individual resident count down record. The DON/designee will do a 2 week look back on documentation of meds not available to ensure appropriate follow up was done. The DON/designee will educate licensed including agency staff on narcotic management and the policy of what to do if a medication is not available. The DON/designee will audit narcotic books to ensure shift to shift count is being completed as well as complete documentation in the index portion of the log book. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed. The DON/designee will audit documentation of medications not available to ensure appropriate follow up was done. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.