Failure to Timely Replace and Document Emergency Medication Kits
Penalty
Summary
The facility failed to ensure timely replacement and proper documentation of emergency medication kits (E-kits) in both the Subacute and Skilled Nursing Facility Medication Rooms, as required by facility policy. In the Subacute Nursing Station, documentation indicated that two vials of Ceftazidime were removed from the E-kit for a resident with sepsis, but subsequent interviews revealed that the medication was not actually removed and the documentation was incorrect. Additionally, the E-kit was not exchanged within the required 72-hour timeframe after being opened, and the pharmacy was not notified promptly for replacement. In the Skilled Nursing Facility Medication Room, the E-kit was found to be opened without the appropriate yellow zip tie or documentation indicating medication removal, and the pharmacy was not notified for replacement as per policy. A resident involved had been admitted with sepsis and was severely cognitively impaired, requiring total assistance for daily activities. Physician orders indicated the need for intravenous antibiotics, and the facility's failure to follow procedures for E-kit management had the potential to delay access to critical medications. Staff interviews confirmed lapses in following the established process for E-kit documentation, notification, and replacement, as outlined in the facility's policy and procedure.