Based on interview and record review it was determined the facility failed to ensure a safe medication system. Findings include:
Refer to tag C-0303.
Action(s) Taken or Planned:
Audit of Med carts to ensure there is not duplicate cards in the carts.
When new orders arrive, triple checks will be completed in a timely manner.
Reports will be ran daily in med system (QMAR) Med Techs will use scanner that is provided with system.
Med pass containers are reviewed for accuracy with 3 residents identifiers.
Action to Prevent Reoccurence:
New orders will be reviewed in a timely manner.
Med techs to be trained on resident rights.
Oversight between shifts to check for competency.
Action Evaluation Frequency:
Weekly, then monthly when competency proven.
Responsible Staff:
Med Techs, RCC, RN, and ED.
Alleged Compliance Date:
03/19/2021
Based on interview and record review, it was confirmed the facility failed to provide a safe medication system. Findings include, but not limited to;
A review of facility records indicated the following medications were missed or carried out against physician's orders;
a. A review of Resident #1's (R1) Medication Administration Record (MAR), dated 09/2020, indicated that on 09/04/2020 three of R1's medications were given to Resident #6 (R6).
A review of R6's Progress Notes dated 09/04/2020 through 09/16/2020, and facility records indicated he/she was given three of R1's medication including two controlled substances and a vitamin.
b. Resident #2's (R2) Medication Administration Record (MAR) and progress notes, dated 09/2020 through 11/2020, medication errors occurred on 09/12 in which another resident's medications was given to R2, 09/26, twice on 09/27, and 09/28 in which pain medications were missed, and twice on 10/26 in which pain medication was missed.
c. Resident #3's (R3) Medication Administration Record (MAR) and progress notes, dated 09/2020 through 11/2020, indicated a medication were missed or administered in error on 10/15/2020, 10/28/2020, 10/29/2020, and on 11/10/2020.
d. Resident #4's (R4) Medication Administration Record (MAR) and progress notes, dated 09/2020 through 11/2020, medication error occurred on 10/08, and on 10/22, 10/23, and 10/24 in which R4 received multiple doses of constipation medication. Records indicated that the prescription medication order changed and was not correctly entered onto R4's MAR, and no monitoring system was set up to guide the new orders.
R4 MAR indicated an order for monthly shots for [vitamin deficiency], starting 08/16/2020 but the syringes were noted to be not available in August, October, and there no indication it was administered November 2020.
In an interview on 12/10/2020, Staff #2 stated that medication are to be reordered 7 days ahead of when that medication is expected to run out based on a color coding of the bubble pack, and when new orders are received they are entered into the residents' MAR.
On 12/16/2020 were reviewed with Staff #1 and Staff #2.
Action(s) Taken or Planned:
Community is ensuring that all new med techs have medication system training (QMAR university) prior to completing training.
Action to Prevent Reoccurence:
Retraining med techs on 'Resident 7 Rights'.
Oversight between shift change to educate and for continuous competency checks.
Action Evaluation Frequency:
Immediately, weekly, then monthly when competency is proven.
Responsible Staff:
Resident Care Coordinator
Alleged Compliance Date:
03/19/2021
