Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to accurately account for controlled medications, affecting two residents. For Resident 87, a discrepancy was found in the Drug Control Receipt Record for clonazepam, where the physical inventory contained one less dose than recorded. LVN 4 admitted to administering the missing dose but failed to document it due to being distracted by other tasks. Similarly, for Resident 93, a discrepancy was noted with lorazepam, where the medication card contained one less dose than recorded. LVN 3 acknowledged administering the dose but forgot to sign it out, highlighting a lapse in maintaining accurate records for controlled substances. In another incident, the facility failed to administer alprazolam to a resident who requested it for anxiety. Resident 347, who was newly admitted with a diagnosis of generalized anxiety, requested the medication at 6 a.m. but did not receive it until after 10 a.m. LVN 6 and LVN 7 both failed to ensure the medication was administered promptly, resulting in a delay that could have exacerbated the resident's anxiety. The facility's policy for timely administration of as-needed medications was not followed, as confirmed by the Director of Nursing. Additionally, the facility did not administer three doses of levothyroxine to Resident 197 as ordered. The resident, diagnosed with hypothyroidism, reported not receiving the medication consistently since admission. A review of the Medication Administration Record revealed that three doses were not administered, which could affect the resident's thyroid function. LVN 1 confirmed the discrepancy and acknowledged the importance of administering medications as ordered to manage the resident's condition effectively.
Plan Of Correction
Request these medications. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. MD was notified about the missed doses on 2/28/25 with no new orders. Licensed Nurses are administering Resident 197's levothyroxine in accordance with the physician order. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents with controlled substances are potentially affected, and residents not receiving medications as ordered by the physician are potentially affected. The Assistant Director of Nursing/designee completed a controlled substance count of controlled medications at the time of the survey on 2/25/2025 to identify potentially affected residents. All controlled substances were compliant during reconciliation, and the deficient practice was isolated to LVN 3 and LVN 4. All residents are potentially affected by not receiving their as-needed medications when requested. Request these medications. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. MD was notified about the missed doses on 2/28/25 with no new orders. Licensed Nurses are administering Resident 197's levothyroxine in accordance with the physician order. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur; License Nurse 7 was re-educated by the Director of Nursing/designee on 2/25/2025, on the facility policy and procedure, "Medication Administration," with emphasis on administering as-needed medications when residents request such medications. LVN 3 and LVN 4 were re-educated by the Director of Nursing/designee on 2/25/2025 on the facility policy and procedure "Administering Medications," with emphasis on the standard of practice pour, pass, chart to ensure medications including controlled substances are signed, reconciled on the narcotic log and medication administration record when the medication is administered. The DSD, as part of the facility's employee orientation, will educate licensed nurses regarding the facility policy and procedure for medication administration, including evaluation of the nurse's competency to pass and reconcile controlled medications, administer medications per physician order, and prompt administration of as-needed medications when residents request the need for such medications. The Director of Staff Development completed a medication pass observation skill competency of LVN 3, 4, 6, & 7 on 3/21/2025. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development is responsible for monitoring licensed and certified nurse assistant staff competency during new hire orientation, annually, and as needed when a variance to standard is identified regarding the facility's "Medication Administration" policy and procedure. Competency-related concerns identified by the DSD will be reported to the Director of Nursing for further review and instruction as indicated. The Consultant Pharmacist will conduct random medication pass observation audits of licensed nurses to ensure medication administration practices are consistent with the standard of practice and facility policy and procedure once per month. Results of the pharmacist audits will be provided to the Director of Nursing and reported to the QAA Committee at a minimum, quarterly, for the purpose of process improvement. The Director of Nursing/designee will report significant findings identified in the medication administration skill competency audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F 755