Deficiencies in Medication Administration and Controlled Substance Documentation
Penalty
Summary
Surveyors identified multiple deficiencies related to pharmacy services and medication administration. One resident did not receive medications in accordance with physician orders, as evidenced by multiple instances where the 9:00 AM dose of prescribed medications was administered outside the required time frame. The facility's Medication Administration Audit Report showed that these medications were given at various times significantly later than scheduled, without a physician order authorizing the change in administration time. Facility policy required medications to be administered as per prescriber orders, including any specified time frames. During a medication storage inspection, it was observed that the shift-to-shift controlled substance count log on one medication cart was presigned for the outgoing slot before the actual count was performed. An LPN acknowledged presigning the log in error and confirmed that the count should be completed and signed together with the incoming nurse at the time of the shift change, as per facility policy. Additionally, the declining inventory logs for controlled substances were not properly signed for two residents. In one case, an LPN administered a controlled medication but failed to sign it out on the declining inventory sheet immediately after administration. In another case, the number of tablets recorded did not match the physical count, and the LPN admitted not signing out the medication at the time of administration. Facility policy required that the count be performed and documented by both incoming and outgoing nurses, and that medications be signed out on the inventory log at the time of administration.
Plan Of Correction
Pharmacy Services CFR(s): 483.45(a)(b)(1)-(3) 483.45 Pharmacy Services 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 177 NJ Ex Order 26.4(b)(1) in the facility. Resident 20 was [R] Resident was interviewed and stated they received their medications accordingly. Resident 58 was [R] Resident was interviewed and stated they received their medications accordingly. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee conducted in-servicing on timely medication administration based on the provider’s order, ensuring documentation of controlled substance medications accurately reflect the disposition and administration times, and accurate shift to shift narcotic counts. Education will continue until all nursing staff have received the in-servicing. Staff will receive the in-servicing prior to working their next scheduled shift. Newly hired staff will receive the in-servicing in orientation when they are hired prior to working the floor. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will conduct audits on 10 resident charts to confirm medications were administered timely. The Director of Nursing or designee will initiate audits on 5 residents who received controlled medication to ensure documentation accurately reflects disposition and medication administration times. The Director of Nursing or designee will initiate audits on 2 random nurses’ shift-to-shift narcotic reports to ensure timely and accurate completion. All audits will be conducted weekly for 4 weeks, then every other week for 4 weeks, and then monthly for 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.