Lee County Health And Rehabilitation

Penalty

Inspection fine: $16,800

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were administered as care planned, which resulted in critical laboratory results not remaining within a therapeutic range for a resident. The resident had a care plan problem dated 1/9/2024, which included an intervention for nursing staff to administer medications and labs as ordered. The goal was to prevent hospitalization related to critical lab values. However, the facility did not follow through with this care plan, leading to a significant deficiency in care. The resident's clinical record revealed diagnoses including liver transplant status and gangrene of the gallbladder in cholecystitis. The resident was prescribed cyclosporine, an anti-rejection medication, to be administered twice daily. Despite the medication running out on 12/29/2023, there was no evidence that the facility's nursing staff followed up with the pharmacy or refilled the medication until 1/2/2024. This lapse in medication administration was documented in the resident's electronic Medication Administration Record (eMAR), showing missed doses on 12/30/2023, 12/31/2023, 1/1/2024, and 1/2/2024. Interviews with staff confirmed that cyclosporine is a critical immunosuppressant medication, and the resident's cyclosporine levels were undetectable due to the medication not being administered. The facility's failure to ensure the availability and administration of the medication as ordered led to a situation where the resident's critical lab values were not maintained within the therapeutic range, posing a risk of serious harm. The facility's noncompliance with the care plan and medication administration requirements was identified as having the likelihood to cause serious injury, harm, impairment, or death to residents.

Removal Plan

• R1 was discharged from the facility and no other residents in the facility are receiving antirejection medication.
• The policy for comprehensive care plans titled Patient's Plan of Care was reviewed by the Administrator, DON, and Divisional Nurse with no revisions made.
• The DON, Assistant Director of Nursing (ADON) and nurse managers reviewed all 58 of 58 resident's medication records and medication carts audited to ensure that medication was available for administration as indicated in the plan of care.
• The Divisional Nurse in-serviced 5 of 5 nurse managers including the DON, ADON, Registered Nurse (RN) Nurse Manager, Resident Assessment Instrument (RAI) Director, and Wound Care Coordinator regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/or discontinue medication as outlined in the facility's policy titled Medication Unavailable for Administration to ensure the plan of care is being followed.
• The DON initiated education for licensed nurses and Certified Medication Aides (CMAs) regarding following the plan of care regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/or discontinue medication as outlined in the facility's policy titled Medication Unavailable for Administration.
• The Divisional Nurse implemented a monitoring tool, F656 Development/Implementation of Comprehensive POC Audit Tool regarding administration of medication to include medication not administered due to unavailability and completed by the DON or nurse managers five times per week, Monday through Friday, to include review of medication administered on weekends.
• 11 of 12 nurses (6 RNs, 6 LPNs for a total of 92%) and 6 of 6 CMAs (for a total of 100%) were educated on documentation and following the plan of care for medication administration.
• The remaining 1 LPN nurse will be in-serviced on the next scheduled workday prior to beginning their shift by the Director of Nursing. Any RNs, LPNs and CMAs that are PRN or on LOA will be provided education upon return to work. Newly hired RNs, LPNs, and CMAs will be provided education during the orientation process.
• The Administrator reviewed the results of the audit during an ADHOC QAPI meeting.
• All Corrective Actions were completed.
• The facility alleges that the IJ is removed.

Penalty

Inspection fine: $16,800

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident obtained medications timely, administered as ordered, and maintained medication trough levels within a therapeutic range. The resident, who had a liver transplant and was diagnosed with gangrene of the gallbladder in cholecystitis, was prescribed cyclosporine, an anti-rejection medication. However, there were multiple instances where the medication was not administered as scheduled, and the facility staff did not follow up with the pharmacy to ensure timely refills. This led to significant lapses in the administration of the medication, which was critical for preventing organ rejection. The resident's cyclosporine trough levels were consistently outside the therapeutic range, with some levels being undetectable, indicating that the medication was not administered properly. Despite the physician's orders and the facility's policy, the nursing staff failed to reorder the medication in a timely manner and did not notify the provider when the medication was unavailable. This resulted in the resident experiencing acute cellular rejection and elevated liver function tests, leading to hospitalization shortly after discharge from the facility. Additionally, there were discrepancies in the administration of other medications, such as mycophenolate mofetil and valganciclovir, with more doses documented as administered than what was provided by the pharmacy. This further highlights the facility's failure to manage and administer medications accurately, putting the resident's health at serious risk. Interviews with staff and family members confirmed the issues with medication administration and the lack of proper communication and follow-up with the pharmacy and healthcare providers.

Removal Plan

• R1 was discharged from the facility, there are no other residents in the facility receiving antirejection medication.
• The policy for Medication Unavailable for Administration was reviewed by the Division Nurse, DON, and Administrator with no changes in policy noted.
• A root cause analysis was identified for medication being unavailable and a Performance Improvement Plan (PIP) was developed regarding CMAs lack of awareness of the reordering process and reporting missing medication to the nurse. The PIP was updated as an allegation of compliance and incorporated into the facility's Quality Assurance Performance Improvement (QAPI) process. An ADHOC QAPI meeting was conducted with the medical director.
• Education was provided by the DON to Licensed Nurses (Registered Nurse (RN) and Licensed Practical Nurse (LPN)) and Certified Medication Aides (CMAs) regarding reordering of medication as outlined in the Medication Unavailable for Administration policy, including best practices for reordering medication when 5-7 days of medication are remaining as well as regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/ or discontinue medication.
• The Divisional Nurse implemented a monitoring tool, F760 Significant Medication Error regarding administration of medication to include medication not administered due to unavailability and completed by the DON or nurse managers five times per week, Monday through Friday, to include review of medication administered on weekends.
• 11 of 12 nurses (6 RNs and 6 LPNs for a total of 93%) and 6 of 6 CMAs (for a total of 100%) were educated on documentation and follow up with pharmacy and MD regarding medications not available and best practices for ordering of medication process.
• The remaining 1 LPN nurse will be in-serviced on the next scheduled workday prior to beginning their shift by the Director of Nursing regarding medication administration that includes inquiry of unavailable medication with the pharmacy, obtaining from back up pharmacy, notifying the provider of unavailable medication and obtaining orders to hold until available or change and/ or discontinue medication. Any RNs, LPNs and CMAs that are PRN or on LOA will be provided education upon return to work. Newly hired RNs, LPNs, and CMAs will be provided education during the orientation process.
• The Administrator reviewed the results of the audit during an ADHOC QAPI meeting.
• All Corrective Actions were completed.
• The facility alleges that the IJ is removed.

Penalty

Inspection fine: $16,800

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the medication error rate was less than 5%, resulting in an observed error rate of 11.4%. This was based on 35 medication administration opportunities with four errors involving three residents. For Resident 2, a Certified Medication Assistant (CMA) failed to administer diclofenac topical gel as scheduled because the medication was not on the cart. The Director of Nursing (DON) confirmed that the medication order did not go through electronically, and the pharmacy was contacted to send the medication later. For Resident 7, the CMA administered Artificial Tears eye drops instead of the prescribed eye ointment and failed to administer lactulose as ordered because it was not available on the medication cart. The DON stated that only the eye drops were available as a stock medication. For Resident 8, a Licensed Practical Nurse (LPN) administered only one 1000 mg cyanocobalamin tablet instead of the prescribed two tablets for age-related osteoporosis. These deficiencies indicate that the facility did not adhere to its policy titled, Medication Administration-General, which requires medications to be administered in accordance with valid prescriber orders. The errors observed included missed doses, incorrect medication forms, and incorrect dosages, all of which were confirmed through staff interviews and record reviews. These failures had the potential to adversely affect the clinical conditions of the residents involved.