Failure to Refill Medications and Maintain Accurate Controlled Substance Counts
Penalty
Summary
The facility failed to ensure that medications were refilled and readily available for two residents who required controlled substances for pain management and sleep. One resident, with diagnoses including lymphedema and chronic pain, reported not receiving Tylenol with Codeine for several days due to the medication running out and not being reordered in time. The resident expressed significant pain and discomfort, stating that regular Tylenol was not sufficient. Another resident, with a history of hemiplegia and psychiatric disorders, reported repeated instances of not receiving Lunesta for sleep because the medication was not refilled before running out, resulting in sleepless nights and frustration. Inspection of the medication cart confirmed that both medications were not available at the time of the survey, and the nurse acknowledged the medications had run out and were awaiting delivery from the pharmacy. Additionally, the facility failed to maintain accurate counts of narcotic medications for two residents. During a controlled substance count, discrepancies were found between the number of pills present in the medication bingo cards and the amounts documented in the controlled drug receipt records. The LPN responsible admitted to administering the medications but forgetting to document the administration, leading to inaccurate records. The facility also did not ensure that controlled substances were counted and documented at the beginning and end of each shift as required. Review of the Controlled Substances Check Forms for multiple medication carts revealed missing signatures for several shifts, indicating that the required shift-to-shift controlled substance counts were not consistently performed or documented. Facility policy requires these counts to be conducted by two licensed nurses at each shift change, but this procedure was not followed for a number of shifts.