Failure to Ensure Proper Pharmaceutical Services and Medication Handling
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of residents, as evidenced by improper handling and documentation of medications, and lack of staff training regarding pharmacy procedures. Observations revealed that two medication blister cards, one for each of two residents, had white tape on the reverse side, which staff interpreted as potential tampering. Multiple staff members, including LVNs and medication aides, reported they had not received training on the acceptance of medication cards with tape or patches from the pharmacy, and were unaware of any facility policy allowing such cards to be accepted. The pharmacy later confirmed that tape was used to correct errors, but there was no written agreement or policy in place to guide staff on this practice. A facility audit identified an additional thirteen blister cards with similar tape, and the facility lacked a policy addressing the use of tape patches by the pharmacy or the acceptance of such cards by nursing staff. Additionally, a narcotic count sheet reconciliation error was discovered during a shift change. An LVN marked a medication as wasted on the count sheet when it had not been wasted, following the direction of the DON, who later acknowledged that this was not the correct procedure. The LVN and DON both signed the correction, despite knowing the information was inaccurate. The nurse involved later realized the error and expressed concern about the potential consequences of falsifying narcotic count sheets. The DON admitted to instructing the LVN to mark the medication as wasted, even though it had actually been administered to another resident, and acknowledged that this was not the appropriate action. The residents involved had significant medical histories, including dementia, chronic pain, and other comorbidities, and were receiving narcotic pain medications as part of their care. Documentation review showed that medication errors and discrepancies were not always recorded in the residents' progress notes, and staff interviews confirmed a lack of training and clear procedures regarding the handling of medication cards with tape or patches. Facility policies on receiving medications and shift change procedures required immediate notification of discrepancies, but did not address the specific issue of pharmacy-applied tape or patches, contributing to confusion and improper medication handling.