Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to adhere to its pharmaceutical procedures, as evidenced by two key observations. During an inspection of the medication storage room on the second floor, the lock box within the medication refrigerator was found unlocked. This lock box contained an emergency kit with several vials, and the Assistant Director of Nursing (ADON) was unable to secure it due to a warped lock. The ADON admitted that this issue had not been reported prior to the survey. This oversight indicates a lapse in the facility's policy that requires all compartments containing drugs and biologicals to be locked when not in use. Additionally, there was a discrepancy in the administration of medication to a resident. The Electronic Medication Administration Record (EMAR) indicated that the resident was to receive a 7.5 mg capsule twice a day, but the resident was being given a 7.5 mg tablet instead. The Licensed Practical Nurse (LPN) involved stated they would contact the pharmacy to verify the order. The facility's Consultant Pharmacist noted that the tablet could be administered with physician authorization, suggesting the documentation error was likely human error. This incident highlights a failure to follow the facility's policy of verifying medication orders and ensuring the correct form of medication is administered to residents.
Plan Of Correction
DISCLAIMER STATEMENT: Preparation and/or execution of this plan of correction in general, or this corrective action in does not constitute an admission or agreement by this facility of the facts alleged or conclusions set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with state and federal laws. This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. 1. On the lock box was repaired. On lock box was replaced lock box. On the 17, 2025, the physician ARNP was contacted, and order was revised: medication was received matching revised order for Resident #180 on the same day. 2. All residents have the potential to be affected by this deficient practice. Facility conducted an audit of all lock boxes to ensure all lock boxes were working correctly and address, if needed. Facility conducted an audit of all orders to ensure physician order matched the type of medication provided by the pharmacy. 3. The Director of Nursing, or designee(s) will educate all staff on Pharmacy Services, Procedures, Pharmacist, Records CFR(s): 483.45(a)(b)(1)-(3), 59A-4.112(1), FAC Pharmacy Policies and Procedures and facilitys Storage of Medications and Administering Medications policies and procedures. 4. The Nurses will conduct medication cart and lock box check daily. The Director of Nursing and/or designee will conduct a weekly medication cart and medication room quality review. The findings will be reported to the Quality Assurance Process Improvement (QAPI) committee monthly and then quarterly once substantial compliance has been achieved.