Medication administration records and narcotic tracking logs did not match for 3 residents receiving opioid pain meds. A resident with chronic pain had multiple hydrocodone removals that were not documented on the MAR, and some MAR entries showed doses given before the narcotic log showed the med was removed. Two other residents also had discrepancies between opioid removal logs and MAR documentation, and staff acknowledged the mismatches.
Pharmacy services failed to ensure two residents received ordered HIV antivirals as prescribed. One resident missed multiple doses of emtricitabine-tenofovir AF and also had a missed dose of azithromycin, while another resident missed multiple doses of bictegravir-emtricitab-tenofov. Staff said the medications were not available in the facility and were delayed because of insurance and pharmacy delivery issues, and the residents reported being told their HIV medications were not available.
A resident admitted from the hospital with diabetes and hypothyroidism missed several ordered meds, including insulin, thyroid meds, a muscle relaxer, and an antacid, because the meds were not available when needed. The MAR and facility investigation showed missed doses on the evening shift after admission, and an LPN later confirmed the meds had not yet arrived from the pharmacy while the resident’s blood sugar was elevated and required physician notification and extra insulin.
Medication transcription errors affected two residents. One resident with COPD had a prednisone order transcribed at half the prescribed dose and received the incorrect dose for four days. Another resident’s MAR omitted atorvastatin and prednisolone acetate eye drops, causing four missed days of both medications. The RN/CNO stated two LNs were expected to double-check hospital discharge orders and admission orders, and acknowledged recent transcription errors had resulted in medication errors.
Missed Physician-Ordered Pain Medications: Two residents did not receive ordered oxycodone on time. One resident with metastatic cancer and a femur fracture had severe pain on admission and did not receive the narcotic until the next morning, while another resident with fibromyalgia missed multiple oxycodone doses because pharmacy access issues and a new script were needed. Staff said the facility had an emergency medication dispensing cabinet, but the ordered pain meds were still not obtained as expected.
Controlled substance records on a medication cart were incomplete and did not consistently show required witness signatures. Pregabalin for a resident was transferred between narcotic book pages without full transfer details, and oxycodone waste entries for another resident did not include a second nurse witness signature; one entry also did not show what happened to the remaining tablets.
Medication administration services failed for multiple residents when two nurses documented meds as given on the MAR even though the meds remained on the cart and were not administered. Residents with severe neurologic impairment, heart disease, diabetes, and HTN missed ordered meds including antihypertensives, anticoagulants, antidiabetics, and an anticonvulsant, and the DON confirmed the doses were not given.
Controlled drugs were not properly tracked or secured in a medication room E-Kit. Surveyors found an unlocked medication refrigerator containing a removable emergency medication box with lorazepam vials and oral solution, a security seal taped to the side instead of securing the box, and no controlled drug logbook. An LPN and the DON stated the refrigerator should have been locked and the controlled drugs counted and logged.
The facility failed to consistently and accurately reconcile controlled medications, resulting in multiple discrepancies between the EMAR and narcotic logs for three residents receiving PRN narcotic analgesics. One resident with an internal hip prosthesis infection had oxycodone doses documented on the EMAR but not on the narcotic log, and vice versa. Another resident with dementia and a lumbar fracture received oxycodone doses documented only 1 hour and 28 minutes apart despite an order for dosing every 4 hours. A third resident with vascular dementia and spinal stenosis had hydrocodone doses signed out twice within a short interval and twice at the same time on consecutive narcotic log pages, without documentation of waste, while the EMAR reflected only single administrations. The Resident Care Manager confirmed the presence of these documentation discrepancies.
A resident on warfarin with an INR goal of 2–3 had multiple INR tests showing fluctuating and at times critically high results, with corresponding changes in warfarin dosing and eventual bleeding symptoms requiring hospital admission. Surveyors found the INR flowsheet for this resident was incomplete and missing several test entries. Staff reported that INR testing was done in-house using a Coag-Sense meter and that quality control (QC) checks were expected when a new box of strips was opened, but there was no formal process to document QC. An opened box of test strips still contained unused high and low control strips matching the lot numbers of strips in use, and staff acknowledged this meant QC testing had not been performed, despite these strips being used for the resident’s INR monitoring.
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