Deficient Management and Documentation of Emergency Drug Supplies and Medication Orders
Penalty
Summary
The facility failed to ensure proper management and documentation of emergency drug supplies (E-kits), resulting in several deficiencies. Upon delivery from the pharmacy, the facility did not receive the correct narcotic E-kit and instead received a C-II E-kit, leaving the facility without a narcotic E-kit for approximately 24 hours. Staff interviews and observations revealed that the narcotic E-kit was missing from its designated location, and only C-II E-kits were present. The facility's policy required staff to check medications against pharmacy order sheets and retain a signed delivery receipt, but this process was not followed, leading to the absence of the required narcotic E-kit. Additionally, the facility did not replace the E-kit within 72 hours of first use, as required by policy. Review of the narcotic E-kit logbook showed entries for medication use that were several weeks apart, indicating that the kit was not replaced in a timely manner. The Director of Nursing confirmed that the dates on the log should not be more than 72 hours apart, but this standard was not met. Furthermore, the facility failed to ensure that drug disposition forms were properly completed; seven forms were found with missing dates and nurse signatures, and some lacked a witnessing nurse's signature altogether. The facility also did not adequately follow up on a resident's order for Norco 10-325 mg, a potent opioid, which was pending authorization from the pharmacy. The medication was not available in the resident's medication drawer, and there was no documentation of follow-up with the pharmacy until prompted by the surveyor. The facility's policy required documentation of non-delivery and follow-up, but this was not done for the resident's Norco order.