Based on interview, record review, and observation, the facility failed to provide a safe medication system. Findings include, but not limited to;
During an unannounced inspection on 08/31/2020, the Compliance Specialist (CS) observed medications/treatment carts to be unsecured and containing resident insulin treatments and supplies.
A review of Resident's #2, #3, #5, #6, and #7 Medication Administration Record (MAR), dated August 2020, indicated one or more medications for one or more consecutive shifts and/or days was unable to be administered due to the medication(s) not being available.
A review of the narcotic inventory count verification from 4 different medication carts, dated August 2020, indicated between 11-22 different days in which the narcotic inventory count verification was either conducted by one staff member only or was not completed on that shift or that day.
A review of Resident #2, #8, #9, and #10s' narcotic inventory page, indicated multiple occurrences in which signatures were missing of the staff member who popped the medication.
A review of Resident #10's [pain] medication narcotic page #61, indicated two tablets were removed, but lacked who and when they were pulled, and a review of this narcotic's administration history did not reflect any administrations of this medication for the unsigned tablets.
A review of Staff #6, #11, #12, #13, and #14's training records, indicated orientation was incomplete, caregiver training incomplete, and medication technicians lacked demonstrated competencies in assigned tasks.
In separate interviews on 08/31/2020, Staff #5 and 6 stated that medications have ran out, staff weren't submitting request for re-orders or following up on requests, and stated the training was not adequate. Staff stated narcotic inventory counts occur at the beginning and end of each shift with the oncoming and outgoing MTs. Residents #1, #2, #6, and #7 stated that medications can ran an hour late, medications have ran out and had to be rushed ordered.
On 08/31/2020 and 09/01/2020, these findings were reviewed with and acknowledged by Staff #1 and #2.
Actions Taken or Planned:
Executive Director and Clinical team will conduct daily stand up meeting and discuss any med errors, MAR audits, ongoing med tech training, follow up with med errors concerns, ongoing communication with Pharmacy and PCP.
On going med tech training for Med Techs to better understand routine vs PRN. Entering of orders in QMAR, ordering medications when low, working with different Pharmacies, (VA, Kaiser, Long term, local Pharmacies) what is the return time when ordering from different Pharmacies.
Clinical team will follow up to make sure that ISP has been completed for any new orders for residents pertaining in increase or decrease in medications.
Residents will be placed on alert charting.
Action to Prevent Reoccurrence:
All medications orders received, RN and LPNs will follow up with Med Tech to make it has been entered in QMAR correctly. RN and LPNs is to follow through to make sure the medications are in house by following up with Pharmacy to make sure the medications has been delivered and administer in accordance with orders.
RN and LPNs will review weekly to make sure that medications are being administered correctly and follow up with Pharmacy to make sure all residents has enough medications in house.
On going Med Tech training on a weekly basis.
Action Evaluation Frequency: Weekly
Responsible Staff: ED RN, LPNs
Alleged Compliance Date: 10/21/2020
Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility. Findings include;
A review of the narcotic inventory count verification from 4 different medication carts, dated August 2020, indicated between 11-22 different days in which the narcotic inventory count verification was either conducted by one staff member only or was not completed on that shift or that day.
A review of Resident #2, #8, #9, and #10s' narcotic inventory page, indicated multiple occurrences in which signatures were missing of the staff member who popped the medication.
A review of Resident #10's [pain] medication narcotic page #61, indicated two tablets were removed, but lacked who and when they were pulled, and a review of this narcotic's administration history did not reflect any administrations of this medication for the unsigned tablets.
In separate interviews on 08/31/2020, Staff #5 and 6 stated that medications have ran out, staff weren't submitting request for re-orders or following up on requests, and stated the training was not adequate. Staff stated narcotic inventory counts occur at the beginning and end of each shift with the oncoming and outgoing MTs
On 08/31/2020 and 09/01/2020, these findings were reviewed with and acknowledged by Staff #1 and #2.
Action(s) Taken or Planned:
Executive Director and Clinical team will conduct daily stand up meeting and discuss any med errors, MAR audits, narcotics, ongoing med tech training, follow up with med errors, MAR audits, narcotics, ongoing med tech training, follow up with med errors concerns, and ongoing communication with Pharmacy and PCP.
On-going med tech training for Med Techs to better understand Routine vs PRN. Narcotics orders, counts and documentation in Narcotic book. This training occurs every Tuesday at 1:30pm.
Clinical team will follow up to make sure that ISP has been completed for any new orders for residents pertaining in increase or decrease in medications. Residents will be placed on alert charting.
Action to Prevent Reoccurrence:
RN and LPNs is to follow up daily.
The Med Tech coming on shift is at the medication cart with the cards and bottles.
That med tech states the number of the card, the resident name (first or last), the name of the drug and how many pills there are.
The Med Tech going off the shift is at the book verifying the count is correct.
Both sign the count sheet that is correct.
If there is a discrepancy at the end of the narcotic count, the med tech must notify RN or ED immediately.
The RN and ED will perform an investigation and notify Pharmacy of any discrepancies.
The RN and ED will do a drug screen if unable to account for the missing narcotics.
If unable to account for missing narcotics, a drug screening of all Med Techs on shift may be performed at this time. One missing or dropped pill may be destroyed by RN.
RN and LPNs to communicate daily with med techs and at change of shift to make sure that they are completing their dashboard before the end of their shift.
RN and LPNs is to check the dashboard daily for any errors. RN and LPNs to provide solutions to Med Techs daily if observe any errors.
ED and RN to follow up daily.
Action Evaluation Frequency: Daily
Responsible Staff: ED, RN, and LPNs.
Alleged Compliance Date: 10/21/2020
Based on interview and record review, it was confirmed the facility failed to carry out medication and treatment orders as prescribed. Findings include, but not limited to:
Based on interview, record review, and observation, the facility failed to provide a safe medication system. Findings include, but not limited to;
During an unannounced inspection on 08/31/2020, the Compliance Specialist (CS) observed medications/treatment carts to be unsecured and containing resident insulin treatments and supplies.
A review of Resident's #2, #3, #5, #6, and #7 Medication Administration Record (MAR), dated August 2020, indicated one or more medications for one or more consecutive shifts and/or days was unable to be administered due to the medication(s) not being available.
In separate interviews on 08/31/2020, Staff #5 and 6 stated that medications have ran out, staff weren't submitting request for re-orders or following up on requests, and stated the training was not adequate. Staff stated narcotic inventory counts occur at the beginning and end of each shift with the oncoming and outgoing MTs. Residents #1, #2, #6, and #7 stated that medications can ran an hour late, medications have ran out and had to be rushed ordered.
On 08/31/2020 and 09/01/2020, these findings were reviewed with and acknowledged by Staff #1 and #2.
Actions Taken or Planned:
Executive Director and Clinical team will conduct daily stand up meeting and discuss any med errors, treatment medications, MAR audits, medication order, what is the arrival time, ordering process, ongoing med tech training, follow up with med errors concerns, treatment medications concern and ongoing communication with Pharmacy and PCP.
Action to Prevent Reoccurrence:
It is expected that medications will be given and documented as ordered.
If at any time a medication is not available when needed, med tech is to notify RN, LPNs, and ED immediately.
If RN/LPNs cannot ensure the medication will be delivered to the community within 4 hours, the ED will be notified.
ED will follow up with Pharmacy to STAT medication needed for resident. STAT refers to immediately or Urgent.
Medications are general deliver within 24 hours of the order being received by the Pharmacy M-F, or the next business day for drugs ordered on the weekend.
Med Techs are to make sure that re-ordering of medications as it is available QMAR. Med Techs are to re-order medications when there are 10 pills left on the bubble pack.
Cycle Fill medications is done in a timely manner and new medications are ordered promptly in order for the resident to receive their medications as ordered by the PCP.
Med Tech is to notify families who provide medications need to be notified of the need for refills far enough in advance to ensure the medication is available when needed.
Med Tech is to document in the QMAR when a family has been requested to obtain medications or medication refills.
Med Tech are to make sure that they go through their dashboard to make sure their tasks are completed.
RN and LPNs is to follow up with the completing of dashboard in QMAR.
Action Evaluation Frequency: Daily
Responsible Staff: ED, RN, and LPNs.
Alleged Compliance Date: 10/21/2020
