Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident 1 no longer resides at facility as of 08/11/25. On 08/13/25, 08/14/25, and 08/15/25, all licensed nurses were in-serviced by DON on medication rights of administration and provided with a copy of the medication administration P&P which states correct administration and documentation -- pour, pass, sign. Licensed nurses were also educated on the one-hour medication pass parameter time. 2. Resident 2 no longer resides at facility as of 08/26/25. On 08/13/25, Resident 2 was assessed by DON for adverse reactions related to missed medication. Resident denied any adverse reactions. MD was notified of missed medications by DON immediately, and no new orders were given. On 08/13/25, DON provided 1:1 training to LVN 1 regarding the rights of medication administration. LVN 1 was provided with facility's P&P on medication administration. DON also provided LVN 1 with 1:1 in-service on proper procedure for medication clarification, documentation, and monitoring. On 08/15/25, Resident 2's medications were revisited and reviewed per physician orders based on Medication Administration Schedule. In addition, a review of resident's chart was conducted by DON. On 08/15/25, Resident 2 was interviewed with daughter at bedside by DON regarding complete medication administration as well as timely medication administration. Resident 2 and daughter validated all medication as well as education was provided, and resident received her medications on time. How the facility will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All current residents with physician order for medication have the potential to be affected by this deficient practice. On 08/13/25, designated licensed nurse conducted a check of all current residents who had received their scheduled morning medications late on 08/13/25. A total of 4 residents out of 91 were affected, attending physicians were notified with orders to monitor for adverse reactions. No adverse reaction noted on 4 residents who were affected by this deficient practice. On 08/13/25, designated licensed nurse conducted an audit on LVN 1's residents with physician's orders for medications. Residents were interviewed by designated licensed nurse, 18 verbal residents stated they received all their medications and were educated on medications administered. On 08/15/25, Resident 2's medications were revisited and reviewed per physician orders based on Medication Administration Schedule. In addition, a review of resident's chart was conducted by DON. On 08/15/25, Resident 2 was interviewed with daughter at bedside by DON regarding complete medication administration as well as timely medication administration. Resident 2 and daughter validated all medication as well as education was provided, and resident received her medications on time. How the facility will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All current residents with physician order for medication have the potential to be affected by this deficient practice. On 08/13/25, designated licensed nurse conducted a check of all current residents who had received their scheduled morning medications late on 08/13/25. A total of 4 residents out of 91 were affected, attending physicians were notified with orders to monitor for adverse reactions. No adverse reaction noted on 4 residents who were affected by this deficient practice. On 08/13/25, designated licensed nurse conducted an audit on LVN 1's residents with physician's orders for medications. Residents were interviewed by designated licensed nurse, 18 verbal residents stated they received all their medications and were educated on medications administered. On 08/14/25, 08/15/25, 08/18/25, 08/20/25, and 08/22/25, DON, DSD, and RN conducted a medication observation for 20 residents to validate pour, pass, sign, timely medication administration, and correct documentation. All 20 residents received their medication on time, and licensed nurses followed pour, pass, sign procedures and accurately documented administration. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 08/13/25, 08/14/25, and 08/15/25, DON provided in-services to all licensed nurses regarding rights of medication administration and facility's P&P on medication administration, specifically "pour, pass, sign." Additionally, DON and/or designee will provide in-services monthly for 4 months and as needed to ensure compliance and competency with P&P. Starting 08/14/25, DON and/or designee will perform a random medication observation of 4 residents per week for 12 weeks and as needed to ensure timely medication administration and accurate documentation. Any deficient findings will be reported to the DON and/or designee for follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON and/or designee will report to the QA&A Committee monthly for review and recommendations for 3 months until substantial compliance is achieved. Completion Date: 08/27/25