Deficiencies in Medication Administration, Controlled Substance Accountability, and Drug Storage/Labeling
Penalty
Summary
Surveyors identified multiple deficiencies related to pharmacy services and medication management. For one resident receiving hemodialysis, scheduled morning medications were not administered after the resident returned from a dialysis appointment, despite physician orders and facility policy requiring administration within a specific time window. Medical record review confirmed that several prescribed medications, including anticoagulants, antidepressants, and diabetes medication, were not given as ordered, and this was verified by nursing staff during interviews. Additionally, the facility failed to maintain proper controlled substance accountability on three medication carts. Narcotic logbooks for these carts showed multiple instances where required signatures from outgoing and incoming licensed nurses were missing during shift changes. Facility policy mandates that two licensed nurses account for all controlled substances and sign the logbooks at each shift change, but this was not consistently followed, as confirmed by staff and the Director of Nursing during interviews and document reviews. Further deficiencies were observed in the labeling and storage of drugs and biologicals. One resident's medication bottle was labeled with an incorrect administration time, and another medication bottle and its corresponding physician order did not specify the prescribed dose. Orally administered medications were not kept separate from externally used medications on medication carts, and opened insulin pens or vials that had exceeded the recommended use period were not promptly removed. Additionally, an opened bottle of anti-fungal powder was found at a resident's bedside without a physician's order. These findings were confirmed through observation, record review, and staff interviews.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 9 was affected by this deficient practice. Immediately on 7/23/2025, RN supervisor clarified resident's 9 medication administration order with primary physician to administer daily medication, scheduled in morning, after resident returned from dialysis. All residents receiving narcotic medication in cart A, B, and C were affected by this deficient practice. Immediately on 7/17/2025, Unit manager and Licensed nurse in charge of the Cart A, B, and C reviewed narcotic logs to make sure all narcotics were accounted for and narcotic log sheet was being signed by incoming and outgoing nurses. 2. 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 were potentially affected by this deficient practice. RN supervisor and Unit manager reviewed all dialysis residents and found no other issue with medication administration during dialysis days. Unit manager reviewed all narcotic logs and found no other issue on other carts. On 8/6/2025-8/8/2025, DON in-serviced all licensed nurses about facility policy and procedure for administration of medication to residents during their dialysis treatment days. DON emphasized clarifying with resident's primary physician any medication administration order that will be conflicted with resident's dialysis treatment time and to make sure to update the plan of care. DON also in-serviced all licensed nurses about policy and procedure of narcotic reconciliation, including making sure signing the narcotic log sheet for incoming and outgoing nurses, and its importance to prevent narcotic diversion. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. RN supervisor or designee will review all new dialysis residents to make sure all their medication administration times do not conflict with their dialysis treatment schedule, and if it does, it will be clarified with primary physician immediately and update the plan of care. IDT will review during clinical meetings (M-F) to make sure the plan of care was being followed. Medical records will be audited for orders and MAR for non-compliance and will be reported to the DON every 3 months. Unit manager or designee will review narcotic log sheets daily for 4 weeks, then weekly thereafter. Any non-compliance with narcotic log sheets will be reported to the DON. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 1 and resident 171 were affected by this deficient practice. Resident 1 is currently not in the facility. On 7/21/2025 and 7/24/2025, Unit manager clarified medication order for resident 171 of Olanzapine and Ferrous sulfate with primary physician and notified pharmacy for correct medication label. All residents were affected by facility failure to separate oral medication vs external use medication in the medication room and medication cart. Immediately on 7/16/2025, RN supervisor and Charge nurse organized the storage to make sure there is a separation between oral medication and external use medication. On 7/17/2025, RN 4 removed the insulin that was opened for more than 28 days per facility P&P, and re-ordered the medication. 2. 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 were potentially affected by this deficient practice. On 8/4/2025, DON and Unit managers reviewed all 10 random residents to ensure all medication labels and orders were correct and found no other issues. On 7/24/2025, Unit manager and RN supervisor checked all medication carts and medication storage to ensure there is a separation between oral medication and external use medications such as suppositories, eye drops, etc., and found no other issues. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurses about facility P&P for medication label management and storage, in particular ensuring physician order and medication label matching. DON also emphasized storage and separation of oral medication and externally used medications to prevent cross-contamination. DON also in-serviced licensed nurses about facility P&P for medication at bedside and verifying medications for new admissions and readmissions from acute care, emphasizing the importance of reconciling all medications with the resident or responsible party. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. RN supervisor or designee will review all new admissions and readmissions to verify orders with physicians, and charge nurses will ensure all medication labels from pharmacy match current physician orders, notifying pharmacy of discrepancies. IDT will review all admissions during clinical meetings (M-F) to ensure all plans of care are in place and all orders verified. Unit managers or designee will conduct daily medication storage checks for 4 weeks and weekly thereafter to ensure oral and external use medications are stored separately. Any non-compliance will be reported to the DON. Department heads and designee will conduct daily room rounds to check for any medication at bedside and address issues immediately, reporting to morning meetings for 3 months. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON will monitor the process's effectiveness and report to the Administrator. Findings will be presented at the Monthly QA&A meeting. The Plan of Correction was presented at the QA&A committee meeting on 08/14/2025. Ongoing audit findings will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025