Failure to Verify and Account for Delivered Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident by not ensuring that medications delivered from the pharmacy were properly checked and accounted for before being signed off by nursing staff. Specifically, an RN signed for a medication delivery without verifying the contents of the package, and the medication could not be located when needed. The Director of Nursing (DON) confirmed that the nurse did not confirm what was in the bag and could not recall who opened the package. The hospice nurse later requested the medication, but it was missing, and the facility was unable to determine its whereabouts. Interviews with several LVNs revealed inconsistent practices regarding the verification and auditing of medication carts (MCs) and the handling of loose medications. LVNs reported that audits of the MCs should be done daily, but loose medications were found at the bottom of the carts, which could indicate that residents did not receive their medications as prescribed. One LVN admitted to never verifying medications sent from the pharmacy, and another described the process for handling controlled medications but did not mention verification of non-controlled medications. The DON and ADM both acknowledged that staff are responsible for verifying and signing off on medications upon receipt, and that failure to do so could result in residents not receiving their medications. Record review showed that the RN who signed for the medication delivery documented receiving specific medications and storing them in the narcotic lock box, but the medications were not found when needed. The facility's policy required medications to be stored safely and securely, with outdated or compromised medications removed immediately. Despite these policies, the lack of proper verification and storage led to the deficiency, as medications were not properly tracked or accounted for, resulting in the potential for residents to miss doses.