Inadequate Nursing Competency and Medication Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff had appropriate competencies and skills to manage controlled and other high‑risk medications for multiple residents. For one male resident with convulsions, hypertension, traumatic brain injury, severely impaired cognition, and extensive to total ADL needs, surveyors found a discrepancy between the control count sheet and the actual volume of Lacosamide oral solution on the medication cart. The control sheet documented 480 mL, while two bottles on the cart contained a total of 510 mL (one unopened 400 mL bottle and one 110 mL bottle). The RN responsible for the cart stated she did not know what to do about the discrepancy, suggested it might be a documentation or measurement error, reported she had not received any skill check‑off on medication administration or control counts since starting three weeks earlier, and did not respond when asked what could have happened if the resident did not receive the prescribed seizure medication dose. A second male resident with dementia, hypertension, diabetes, moderately impaired cognition, and supervision to partial assistance with ADLs had an active care plan for pain management and an order for PRN tramadol. During a controlled substance count on the same medication cart, surveyors observed that one tramadol blister in the resident’s card had a punched seal with the tablet half exposed. The RN stated the seal was punched and she did not know what to do, and also reported she had not received training on medication administration or control counts. The DON later stated that if a tramadol blister pack seal was broken, the nurse should waste the medication with another nurse and sign the control sheet, and that if the medication in the opened blister was not taken out and destroyed, it could have gone missing and would have been reportable for drug diversion. A third female resident with obesity, hypertension, diabetes, intact cognition, and independence to supervision with ADLs had a care plan for pain medication therapy and an order for PRN acetaminophen‑codeine. Review of the control count sheet showed 16 tablets documented, but surveyors found only 15 tablets in the blister pack on a different medication cart. The LVN assigned to that cart stated she had administered one tablet earlier that afternoon and forgot to sign it out on the control sheet or the MAR, and when asked when she should have signed the control book and MAR, she shrugged her shoulders. She reported having no medication administration training since starting three weeks earlier, aside from three days of floor orientation. The DON acknowledged that the LVN should have signed out the medication immediately when it was pulled and administered, and also stated that comprehensive nursing training had not been completed due to ongoing staffing needs, despite the facility’s written policy requiring nursing leadership to establish and monitor competency requirements and training for nursing staff.
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