Controlled medication handling was inaccurate for one resident and improper wasting procedures were used for two residents. An LPN and the off-going nurse missed a missing tablet during the narcotic count, leaving the count off by one, and two other residents’ popped controlled meds were taped back into blister packs instead of being wasted with a second nurse present, as expected by the DON.
Failure to Administer Ordered Prednisone: A resident with COPD, cough, congestion, and other respiratory diagnoses was ordered Prednisone for 4 days, but the MAR and nursing notes showed doses were not given because staff were waiting on pharmacy. The resident was observed coughing up phlegm and stated she had been supposed to start a steroid but had not. An LPN confirmed the medication was not delivered and was not administered as ordered, and the NP confirmed the order was expected to be carried out.
Incomplete Controlled Substance Reconciliation on Medication Carts: The facility failed to accurately reconcile controlled substances on 2 of 3 medication carts reviewed. Controlled Drugs-Count Records for Medication Cart b and Medication Cart c had missing oncoming and off-going nurse signatures across multiple shifts, despite policy requiring both nurses to count controlled meds together and document the count each shift. An LPN stated the signatures confirmed accurate reconciliation, and the DON confirmed the records were not completed as required.
A resident's narcotic record was not maintained and reconciled when an LPN administered Pregabalin 25 mg but failed to sign it out on the resident's Individual Narcotic Record. During observation, the documented count was 47 while the actual count on the narcotic card was 46, and the LPN confirmed the medication should have been signed out at the time of administration.
Controlled drug counts were not accurately reconciled for two medication carts. An LPN documented controlled meds as administered or prepared for administration, but the packets and narcotic records did not match for a resident’s alprazolam, another resident’s lorazepam, and a third resident’s tramadol. The LPN confirmed the discrepancies and stated the meds were not signed out at the time of administration, and the DON stated the narcotic record should accurately reflect the quantity available at all times.
Medication at Bedside Without Physician Order: A cognitively intact resident with DM2 and dermatitis had a bottle of generic Benadryl on her bedside table on multiple observations, even though there was no physician order allowing self-administration. An LPN and the DON confirmed residents need a physician order to keep medications at the bedside and that the resident should not have had medication in her room.
Surveyors found that the facility failed to ensure an ordered antihypertensive medication was available and administered as prescribed. A resident with essential HTN had a standing order for Hydralazine 10 mg PO BID, but during a medication pass an LPN did not have the drug on the cart or in storage, and confirmed it was not in the facility. Record review showed the last dose was given the prior evening and that the next scheduled morning dose was not documented as administered. The LPN acknowledged the medication had not been reordered in advance as required by facility policy, and the administrator confirmed that medications ordered by physicians are expected to be available at all times and refilled before running out.
Failure to Administer Ordered BP Medication: A resident with hypertensive heart disease had orders for Norvasc at bedtime and Metoprolol BID with specific hold parameters. EMAR review showed the Norvasc dose was repeatedly not given and was documented as held for vitals outside parameters, even though the resident’s BP readings met the Norvasc order; an LPN said she held the meds because the pulse was out of range, and the DON confirmed Norvasc should have been administered.
A resident with chronic atrial fibrillation, CHF, HTN, and CAD missed ordered Amiodarone doses because the medication was unavailable at the facility. The MAR documented the doses as not given, and progress notes stated the facility was awaiting delivery from pharmacy, but an LPN did not contact the pharmacy or the provider about the missed doses. The DON confirmed staff should have contacted both the pharmacy and the prescribing provider, and one LPN acknowledged an error in documentation showing the medication had been given when it had not.
Narcotic logs for a resident’s hydrocodone-acetaminophen were not accurately reconciled, with an LPN documenting the same dose twice and conflicting remaining counts. The resident also did not have the ordered pain medication available when due, despite one tablet being observed earlier; later notes stated the med was out and waiting on hospice pharmacy, and the DON confirmed it should have been available.
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