Pharmacy Service Deficiencies at Lakewood Rehabilitation
Penalty
Summary
Lakewood Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding pharmacy services. The facility failed to provide timely pharmaceutical services to meet the needs of two residents. Resident 1, who was admitted with a prescription for oxycodone-acetaminophen for severe pain, experienced delays in receiving the medication upon admission. The facility cited pharmacy delivery issues as the reason for the delay, and there was no documented evidence explaining why the medication was not administered despite the availability of an emergency supply. Additionally, there were discrepancies in the accounting of narcotic medications for Resident 1, with tablets signed out by nursing staff but not documented as administered. Resident 2, admitted with prescriptions for Effexor and other medications, also faced delays in receiving prescribed medications. Effexor was not ordered until several days after admission, and there was no documentation explaining the delay. Furthermore, Resident 2's nighttime medications were not administered as scheduled on the day of admission, with no explanation provided for the omission. Both residents reported experiencing delays in receiving their medications, which the facility confirmed during interviews. The facility's failure to ensure timely acquisition and administration of medications, as well as proper accounting of controlled substances, resulted in non-compliance with pharmacy service regulations. The Nursing Home Administrator and Corporate Nurse Consultant acknowledged the deficiencies, confirming the facility's responsibility to meet residents' pharmaceutical needs.
Plan Of Correction
1. Resident R 1 discharged from the facility to home on 2/08/25. Resident R 2 discharged from the facility to home on 2/08/25. 2. Current residents admitted to the facility in the past 7 days have been reviewed to ensure that hospital discharge medications are transcribed as ordered and available for administration. Current residents with physician orders for narcotic medications have been reviewed to ensure narcotic count sheets are in place and accurate for medication administration. 3. Licensed nurses will be reeducated by the DON and or designee to correct transcription of admission medications and scheduling to ensure medication availability. Licensed nurses will be reeducated by the DON and or designee to the facility process for narcotic administration including the documentation for accounting of narcotic medications. 4. Audits will be completed twice weekly by the Clinical administrative team, x 2 weeks, then monthly x 2 months, to ensure new resident medications are available for administration, per physician orders. Audits will be completed twice weekly by the Clinical administrative team, x 2 weeks, then monthly x 2 months, to ensure narcotic medications administered are being accurately documented per the facility process for narcotic medication administration records. Trends will be reviewed by the QAPI committee for further follow-up as needed.