A medication cart narcotic count on Hall 200 was not correctly reconciled. A CMA recorded a count of 17 cards, but the narcotic control substance form had already documented 15 cards at shift start, and the CMA stated no cards had been added and that the count had been prewritten before she arrived. The DON stated staff should not pre-document the narcotic count and later acknowledged the actual count was 17.
The facility failed to ensure medications were administered according to physician orders for two residents. One resident missed alprazolam doses because staff were waiting on pharmacy or delivery, and the resident reported not receiving anxiety medication for several days because the facility ran out. Another resident’s MAR had multiple blank entries for ordered meds, and the DON found pantoprazole packets still in the cart with all doses present, indicating the medication was probably not given as ordered.
A resident ordered IV ampicillin for cellulitis missed a scheduled dose because the medication was not alerted for administration after being transcribed between the MAR and TAR. An LPN stated the dose was not given because the system did not alert staff, and the DON acknowledged awareness of the missed medication.
Medication administration was not documented as ordered for a resident with epilepsy and heart failure. The resident had seizure activity after a levetiracetam dose change from 750 mg BID to 1000 mg BID, but the MAR did not show the evening dose or the next day’s two doses were given, and the DON stated there was no documentation that the medication was administered for those doses.
Medications Not Available for Ordered Administration: The facility failed to ensure ordered meds were available for administration for two residents. One resident’s MAR showed missed doses of Modafinil and Xalatan eye drops because the meds were not available, and another resident’s MAR/TAR showed missed doses of Cefdinir and ipratropium bromide-albuterol because the meds were not available or were on order. The DON stated the meds should have been available and administered as ordered.
Expired and discontinued Lorazepam Oral Concentrate for a resident was found in the medication room refrigerator during survey. The medication had been discontinued earlier and had also passed its expiration date, despite the facility policy requiring expired meds to be removed from active supply and destroyed. A CMA removed the medication after it was identified, and the DON stated it should have been removed when discontinued or by the expiration date at the latest.
Incorrect Insulin Dose Administered: A resident with DM received the wrong sliding-scale dose of Fiasp after a finger stick blood sugar of 190. An RN administered 9 units instead of the ordered 6 units and later stated they did not know they had given the incorrect dose and would notify the DON of the med error.
A resident with dementia, restless leg syndrome, and anxiety had physician orders for ropinirole at bedtime and twice daily, but the MAR showed missed doses because the medication was on order and awaiting delivery. Staff interviews indicated meds should be reordered when about a week’s supply remained, and if delivery was delayed, the pharmacy should be called.
The facility failed to maintain an effective system for receiving, documenting, and reconciling controlled narcotics, resulting in missing oxycodone/APAP and hydrocodone/APAP for two residents with chronic pain and major depressive disorder. Pharmacy records showed full quantities of controlled medications were delivered, but medication cards and count sheets for significant portions of these drugs could not be located, and the receiving logs did not reflect the deliveries. For one resident, the controlled drug count sheet showed doses documented as given that were not recorded on the MAR, while the resident reported taking only one dose and a CMA reported their signature had been forged on the count sheet. For the other resident, reconciliation of count sheets and packing slips revealed 30 tablets unaccounted for, with incomplete count sheets for the month. Staff interviews showed inconsistent reconciliation practices and acknowledged a period without a full-time DON during which these discrepancies occurred.
A resident with orders for levothyroxine for hypothyroidism and divalproex for dementia did not receive multiple scheduled doses because the medications were not available in the building. Review of the MAR showed several early-morning levothyroxine doses and morning divalproex doses marked as held due to unavailability or lacking documentation. CMAs reported that medications were ordered when supplies were low and that unavailable medications were left on the MAR while notifying nursing staff, pharmacy, and the DON, while leadership stated medications should be reordered earlier and STAT if needed. These discrepancies in practice led to repeated missed doses of the resident’s prescribed medications.
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