Failure to Replace E-Kits and Document Controlled Substance Disposal
Summary
The facility failed to adhere to its policy and procedure regarding the replacement of portable container non-antibiotic medication Emergency-Kits (E-Kits) within the stipulated 48-72 hours. During an observation and interview, it was found that two E-Kits with red zip ties, indicating they had been opened, were not replaced in a timely manner. One E-Kit had been opened since February 25, 2025, and the other since December 23, 2024, yet neither had been replaced. The Licensed Vocational Nurse (LVN) acknowledged the importance of having the E-Kit available for emergencies to prevent delays in treatment. The Director of Nursing (DON) confirmed the lack of documentation or monitoring logs to ensure E-Kits were checked daily, which could lead to delays in care during emergencies. The facility also failed to implement its policy on the disposal of medications and medication-related supplies, specifically regarding the destruction of controlled substances. During an inspection, it was revealed that 24 resident medications were disposed of without the required signature of a licensed nurse witnessing the destruction. The DON admitted to being the only licensed nurse responsible for the destruction process and failed to sign the Controlled Drug Record sheets due to being occupied with other tasks. This oversight left the destruction process undocumented, raising concerns about potential diversion and theft of medications. The facility's policy indicated that controlled substances should be securely locked until destroyed by a DEA representative or by the facility's DON and/or consultant pharmacist. However, the DON's failure to follow this procedure and the absence of a second signature on the destruction forms compromised the integrity of the medication disposal process. The lack of adherence to these policies placed residents at risk of not receiving necessary medications during emergencies and increased the potential for loss or diversion of controlled substances.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/7/25, the Director of Nursing had the facility's Emergency kit (E-Kit) replaced. There were no negative or adverse outcomes noted related to this deficient practice. On 3/6/25, the Director of Nursing (DON) presented the facility's Controlled Drug Record dated 12/12/2024 without the signature of a licensed nurse witnessing the destruction of the medications. Medication was destroyed in the presence of the Pharmacist. There were no negative outcomes as a result of this deficient practice. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/7/25, the Infection Control Preventionist conducted a visual round to ensure all E-kits were not expired. No other residents were affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the past quarter of medication destruction sheets. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), on the facility's policy and procedure titled, "Medication Ordering and Receiving from Pharmacy," undated, with emphasis on emergency needs for medication being met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The in-service included nursing calling the pharmacy as soon as possible for replacement of the kit/dose and flagging the kit with a color-coded lock to indicate need for replacement of kit/dose. The in-service also emphasized that if exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening, and if replacing used medications, the replacement doses are added to the kit within 72 hours of opening. On 3/12/25, the facility created an E-Kit monitoring log and in-serviced Nursing Staff, including but not limited to LVNs and RNs, on how and when to complete it. The DON/designee will conduct audits daily for five days weekly for two weeks, then monthly for three months to ensure E-kits are not expired and logs are completed for monitoring. On 3/17/25, the facility's assigned Pharmacist from Star Pharmacy in-serviced the Director of Nursing (DON) and Registered Nurse (RN) on the facility's policy and procedure titled, "Disposal of Medications and Medication-Related Supplies," with emphasis on controlled substances being retained in a securely locked area with restricted access until destroyed by a Drug Enforcement Administration (DEA) representative or by the facility director of nursing and/or consultant pharmacist and/or administrator. The in-service also included ensuring signatures of licensed nurses witnessing the destruction of the medications. The Medical Records Director will conduct an audit on the medication destruction sheets monthly and as needed (PRN) to ensure signatures include the signature of a licensed nurse witnessing the destruction of the medications. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility's E-kits not being expired for three months or until compliance is met. The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance with medication destruction and disposal, ensuring a signature of a licensed nurse witnessing the destruction of the medications, for three months or until compliance is met.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to reconcile liquid controlled narcotics during a shift change count. An RN counted only the pill narcotics in the locked med cart box and left 7 bottles of liquid controlled meds uncounted, stating liquid morphine was hard to count. Other staff, including the DON and consulting pharmacist, confirmed that all controlled meds, including liquids, should be reconciled shift to shift per policy.
Incorrect Medication Route Transcribed on MAR: A resident with cerebral infarction, dysphagia, and gastrostomy status had an order for acetaminophen 650 mg by mouth PRN pain, but the MAR reflected the route incorrectly. During observation, the resident received medications through the G-tube, and the LVN stated she had transcribed the wrong route into PCC even though the resident was NPO. The DON stated new orders are transcribed by the charge nurse and reviewed by nurse managers.
A resident with cognitive intactness, wheelchair use, and multiple diagnoses had groin redness and a provider order for nystatin powder, but staff also kept an unlabeled bottle of 2% miconazole nitrate at the bedside without a provider order. Staff and the resident described self-administration, yet the TMA documented the ordered nystatin as given even though she later said it remained in the cart and was not administered, and staff were unclear about which antifungal powder was being used.
Failure to Monitor Controlled Narcotics in E-kit: The facility failed to monitor controlled narcotic medications in an E-kit stored in a med cart. RN-A stated the plastic numbered tag on the E-kit was not checked daily or documented, and both RN-A and TMA-A said there would be no way to know if the kit had been opened and narcotics removed until the kit was accessed for needed meds. The E-kit contained controlled meds including tramadol, hydrocodone/APAP, lorazepam, and morphine solution, and the DON stated staff should have been monitoring the tag number.
A resident with diabetes had insulin glargine documented as held on multiple occasions even though the DON stated it was administered as ordered, and a second resident's PRN Norco was signed out on the controlled drug record but not documented on the MAR. Facility policy required medications to be given per MD order and controlled meds to be documented on both the accountability record and MAR.
An LVN prepared medications for two residents on one tray and intended to administer them one after the other, rather than for one resident at a time. One resident had osteoarthritis and the other had liver cancer; both were cognitively intact and required substantial to maximal assistance with ADLs. During observation, the LVN carried two medication cups and water into the roommates’ room, gave one resident’s medication while the other was busy, and stated she saw no issue with preparing and administering both residents’ medications together. The DON stated medications should be prepared and given to one resident at a time, and facility policy said medications are administered when prepared and are not pre-poured.
Failure to Reconcile Liquid Controlled Narcotics During Shift Change
Penalty
Summary
The facility failed to reconcile liquid controlled narcotic medications in 1 of 2 medication carts during the shift change narcotic count. During observation and interview, RN-B counted the narcotic pills in the locked box of the medication cart while LPN-A confirmed the pill count, then RN-B locked the box and cart without picking up or confirming the amounts of 7 bottles of liquid narcotic medications also stored in the locked box. RN-B stated the liquid morphine was not counted because it is hard to tell as a liquid, although the facility documented administration of the liquid narcotics in the narcotic book. The unreconciled medications included liquid morphine, codeine solution, and lorazepam solution for residents R7, R8, R23, R26, R36, and R53. Interviews with other nursing staff, the DON, the regional clinical service director, and the consulting pharmacist confirmed that all controlled medications, including liquid narcotics, should be reconciled shift to shift. Staff stated that everything in the locked box should be counted to confirm the correct amount remained, and the DON identified that nurses should count all narcotics between two staff members. Review of the facility's controlled medication policy stated that all controlled medications are to be verified when delivered and that each time the keys secure the controlled medication locked box, the oncoming and off-going nurse or medication aide should reconcile all controlled medications to ensure the count matches the remaining amount listed.
Incorrect Medication Route Transcribed on MAR
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #35 by inaccurately transcribing a physician-ordered medication onto the Medication Administration Record. Resident #35 was an adult male admitted with diagnoses including cerebral infarction, dysphagia of the oropharyngeal phase, and gastrostomy status, and his care plan identified that he required tube feeding related to stroke. His orders included NPO status and an order for acetaminophen 325 mg tablets, 2 tablets by mouth every 6 hours as needed for pain. During observation of medication administration, the resident did not receive acetaminophen, and scheduled medications were administered through the gastrostomy tube. Record review showed the MAR documented acetaminophen 650 mg as given, but the route was reflected incorrectly. The LVN who received the original order stated she had accidentally marked the wrong route when transcribing it into PCC and that she administered the dose through the gastrostomy tube because the resident was NPO. The DON stated the charge nurse is responsible for transcribing new physician orders into PCC right away and that the incorrect route was missed during review.
Medication Given and Documented Without Proper Order
Penalty
Summary
The facility failed to follow provider orders for medication and failed to ensure medication administration was correctly documented for one resident who was cognitively intact, used a wheelchair, and had diagnoses including bilateral subdural hematomas related to a fall, congestive heart failure, and chronic kidney disease. The resident was occasionally incontinent of urine and required moderate assistance with lower body dressing and toileting. A nursing progress note documented redness in the groin related to moisture, and the provider later ordered nystatin external powder to the groin three times daily for 14 days for candidiasis related to rash and other nonspecific skin eruption. Despite that order, the resident’s record did not contain a provider order for 2% miconazole nitrate powder. Surveyors observed a container of 2% miconazole nitrate antifungal powder on the resident’s bedside table on two occasions, and the container did not have a pharmacy prescription label. The resident stated staff had given him the powder and that he could use it as needed, while a nursing assistant stated staff were supposed to help apply it but the resident preferred to do it himself and refused staff assistance or removal of the medication from the room. During interviews, nursing staff stated orders should be in the system for all medications, including topicals and self-administered medications. A review of the MAR showed the nystatin powder was documented as administered, but the TMA later stated it had remained in the cart that morning and was not given, and that she charted it as administered after the resident said he would do it later and later told her he had done it himself. The TMA also produced a separate bottle of 2% miconazole nitrate from the medication cart and confused it with the nystatin order, while the DON stated no medications should be administered without a provider order and that medication administration should be documented accurately.
Failure to Monitor Controlled Narcotics in E-kit
Penalty
Summary
The facility failed to monitor controlled narcotic medications in 1 of 1 emergency kits (E-kits) to prevent potential diversion. During observation and interview, the E-kit was found stored in the medication cart, with a small plastic E-kit box inside a locked box on the cart containing controlled narcotic medications. RN-A stated the nurses did not monitor the plastic numbered tag on the E-kits daily, and the tag was not documented anywhere to confirm the correct tag remained in place. Both TMA-A and RN-A stated there would be no way to know if someone had opened the E-kit and removed narcotics until the nurse accessed it for needed medication, and RN-A acknowledged the kit and the smaller box were not opened regularly, so medication could be missing for quite some time before anyone would notice. Review of the E-kit medication list showed controlled narcotics including Tramadol 50 mg, Hydrocodone/APAP 5/325 mg, Lorazepam 0.5 mg, and Morphine solution 20 mg/ml. The DON stated staff should have been monitoring the number on the plastic tag of the E-kit and the E-kit located inside the locked box on the medication cart, and a policy on monitoring controlled narcotic medications was requested but not provided.
Medication Administration and Controlled Drug Documentation Errors
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders for two residents. For one resident with diabetes mellitus, the physician ordered insulin glargine 27 units subcutaneously at bedtime and regular human insulin before meals and at bedtime per sliding scale. The order summary did not include any hold parameters for insulin glargine, yet the MAR showed the insulin glargine dose was held on multiple dates in July 2026. On those same dates, the regular human insulin was held appropriately based on the documented blood sugar values. During interview and record review, the DON acknowledged the insulin glargine doses were shown as held on the MAR but stated the medication had been administered as ordered. For another resident, the physician ordered hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every four hours as needed for severe pain, not to exceed 3 g in 24 hours. The facility's controlled medication record showed one tablet was dispensed and signed out, but the MAR did not show documentation that the dose was administered. The resident's H&P indicated the resident had the capacity to understand and make decisions. An LVN and later the DON reviewed the record and verified that the medication had been pulled and that there was no documented evidence on the MAR. Facility policy required medications to be administered according to physician orders and required controlled medications to be documented on both the accountability record and the MAR at the time of administration. The survey findings showed that insulin glargine was documented as held on the MAR despite the DON stating it had been given, and that a controlled pain medication was signed out but not documented as administered on the MAR.
Medication Prepared for Two Residents on One Tray
Penalty
Summary
The facility failed to ensure that an LVN did not prepare medication for two residents on one tray with the intent of administering the medications sequentially. Resident 4 had osteoarthritis, intact cognition, and required substantial to maximal assistance with ADLs; his physician’s order included hydrocodone-acetaminophen 10-325 mg, one tablet every 4 hours as needed for severe pain. Resident 5 had liver cancer, intact cognition, and required substantial to maximal assistance with ADLs; her physician’s order included oxycodone HCl 5 mg every eight hours for pain. During a medication administration observation, the LVN was seen carrying two medication cups, each with one pill, and two cups of water on one tray to the roommates’ room. When Resident 5 was being transferred from a wheelchair to the bed, the LVN stated she would administer Resident 4’s medication first and return later for Resident 5’s medication. The LVN stated she knew both residents well and saw no issue with preparing and administering their medications together. The DON stated medications should be prepared and given to one resident at a time because preparing medication for multiple residents simultaneously could result in giving the wrong medication to the wrong resident. The facility policy stated medications are administered at the time they are prepared and are not pre-poured, and medications are administered without necessary interruptions.
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