A resident with ESRD, DM2, depression, anxiety, bipolar disorder, and parkinsonism did not receive ordered Renvela for an extended period despite an active EMAR order. Review showed repeated hold periods and no doses administered across multiple months, while the dialysis RD said the medication was used for elevated phosphorus and had been filled previously. Staff interviews showed confusion about whether dialysis or the facility pharmacy should refill the medication, and the DON confirmed the medication was not readily available even though it should have been.
Delayed Medication Delivery and Missed Administration: Two residents did not receive ordered meds because the facility failed to timely send admission orders to the pharmacy. MARs showed code 5 for multiple scheduled meds, and notes documented the meds were on hold pending pharmacy delivery. The pharmacist confirmed the orders were received late, and an LPN and the DON acknowledged the delays.
Incomplete controlled substance reconciliation documentation was found for 4 medication carts. The Narcotic Nurse Sign Off Logs showed multiple missing signatures from both off-going and oncoming nurses, despite the facility policy requiring the nurses to count controlled meds together at shift change and sign the log to show an accurate count with no discrepancies. An LPN and the DON confirmed the expected shift-change reconciliation process.
Missed medication doses occurred when staff failed to ensure ordered drugs were available and administered as prescribed. A resident with pain and psychiatric orders missed Lidocaine patches and Risperidone, two residents with anticoagulant and UTI prophylaxis orders missed Eliquis and Macrobid, and another resident missed Pregabalin doses. Staff documented medications as unavailable, did not consistently notify the NP, DON, or pharmacy, and did not check the emergency kit even when the medications were listed there.
Medication Not Available for Scheduled Dose: A resident with essential HTN had an order for daily Metoprolol ER, but the LPN did not have the medication on the cart or in storage during the scheduled med pass. The LPN confirmed it had not been reordered from the pharmacy, and the pharmacist and ADON confirmed no refill request had been made even though the medication should have been available for administration.
Expired medications were found available for use on a medication cart, including a resident’s Tramadol 50 mg and another resident’s Cyclobenzaprine 5 mg. An LPN confirmed the medications were expired and should not have been on the cart, and the DON confirmed they had not been properly disposed of per policy.
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.
A resident's ordered Losartan 50 mg was due during the morning med pass, but an LPN reported it was not available for administration. Review of the physician orders confirmed the medication was scheduled for the morning pass, and the DON was later informed that the medication was still unavailable.
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.
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