A resident with lung cancer, chronic pain, and palliative care needs had multiple medication transcription errors and missing controlled substances. A fentanyl patch order was re-entered incorrectly, causing the MAR to generate the wrong patch schedule, and later two separate incidents involved fentanyl patches that could not be located during checks. Oxycodone orders were also entered incorrectly, leaving out overnight doses on the MAR until the schedule was corrected, and staff acknowledged they did not fully review the orders or generated administration times.
A resident with a right femur fracture and pain related to a right hip prosthesis had an order for tramadol 100 mg PRN, but staff borrowed tramadol 50 mg from another resident’s supply and administered medication without following the ordered dose. RN and LPN interviews showed uncertainty about where the medication came from, and the DON confirmed controlled substances are not to be borrowed from another resident and must be obtained through approved systems.
A resident with anxiety and insomnia did not receive clonazepam as ordered because the medication was unavailable in both the resident supply and the emergency stock. MAR entries were unsigned or referenced progress notes, nursing notes documented delays awaiting pharmacy delivery, and the DNS stated the emergency supply should have included the medication but was not regularly stocked.
An LPN was observed handling morphine and another medication from the med cart without first checking the MAR, and she later acknowledged drawing up morphine from a leaking bottle and putting it back into the bottle. Shift-change narcotic documentation showed a wet morphine box and an entry for waste, but the time and amount wasted were not recorded, and the controlled substance audit process did not reconcile unit records with the pharmacy proof of use sheets.
The facility failed to ensure accurate reconciliation of controlled substances at shift change. Review of narcotics and sedatives count sheets for three units showed multiple missed documentation entries across two months, and the DON stated the licensed nurse was responsible for completing the count at every shift change. The Controlled Substance policy required counts at receipt, administration, disposition, and the end of each shift, with the oncoming and offgoing nurses counting together.
A resident with chronic pain and severe cognitive impairment did not receive an ordered Schedule II pain medication when the supply ran out and the order was later placed on hold because of an insurance preauthorization issue that the facility was unaware of. In addition, two residents had hydromorphone administrations recorded on the controlled substance log but not on the MAR by LPNs, and expired hydromorphone packs and records were still found in the locked med cart after the orders had ended.
A resident with anxiety, dermatitis, and hypothyroidism did not consistently receive ordered medications, including Levothyroxine, Xanax, and Dupixent, as documented on the MAR. Levothyroxine doses were missed on consecutive days, with one omission unexplained and another marked as not available despite prior delivery from the pharmacy, and no provider notification was documented. A scheduled Dupixent dose was delayed due to unavailability, and a Xanax dose was missed and marked as not available even though the medication had been received, again without documented provider notification. An APRN later noted the resident experienced intermittent seizure-like activity when the morning Xanax dose was missed and stated she should have been notified of omissions. Interviews with the DNS and LPNs revealed issues with agency staff marking medications as not available, failure to verify and obtain medications from stock or pharmacy, and lack of provider notification, contrary to facility medication administration and documentation policy.
A resident with seizure disorder, dementia, and multiple comorbidities experienced repeated failures in timely medication administration and documentation. Required scheduled doses of gabapentin and acetaminophen were not documented as given at the ordered time, despite an RN later stating they had been administered. On another day, an RN documented a set of 9:00 AM medications, including anticonvulsants, antihypertensives, anticoagulant, antidepressant, and laxative, more than four hours late, while another RN administered evening anticonvulsant, analgesic, muscle relaxant, anticoagulant, sleep aid, antidepressant, and neuropathy medications more than two to three hours earlier than scheduled. One RN reported routinely delaying electronic documentation until after completing the full med pass due to EMR issues and workload, contrary to the facility’s one-hour administration window and immediate documentation standard.
The facility failed to maintain proper control and accountability of discontinued narcotic medications, resulting in missing Oxycodone and Lorazepam tablets for three residents with pain, dementia, and anxiety. Discontinued controlled drugs remained in unit narcotic lock boxes instead of being promptly removed to a secured nursing office lock box, and both the white proof-of-use sheets and matching medication packs went missing. An LPN’s narcotic audits did not include MAR review, discrepancies were adjusted to match proof-of-use sheets, and required dual nurse signatures for end-of-shift narcotic counts were missing on multiple dates. These actions and omissions violated the facility’s own controlled substance handling policy and led to unaccounted-for controlled substances.
Lack of Controlled Medication Reconciliation Process: The facility failed to maintain a process for controlled med audits and reconciliation. The ADNS said bi-weekly audits were done by counting meds at the carts and matching white and yellow CSDRs later, but she did not bring the yellow CSDR binders to the audits and could not identify a policy for the process. Surveyors found yellow CSDRs dating back over time, 23 records flagged for reconciliation, and the facility leadership stated there was no policy directing the audits. The ADNS reconciled 22 records but could not account for Tramadol HCL 50 mg half tablets received earlier.
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