Based on record review and interview, conducted during a site visit on 04/30/24, it was confirmed the facility failed to ensure staff visually observe residents take medications for 1 of 1 sampled Resident (#1). Findings include, but are not limited to:  

Resident 1's MAR dated 03/02/24 through 03/31/24, observation notes dated 03/01/24 through 03/31/24, incident report dated 03/04/24 and Physicians orders the following deficiency was identified:

"MAR indicated resident did not take nighttime medications on 03/03/24 and was trying to take them the following morning on 04/04/24, resident missed carbidopa, trazadone, and citalopram.

"Observation notes indicate 03/04/24 resident placed on alert charting for missed medication.

"Incident report dated 03/04/24 indicated "when morning shift MT went into residents' room, she discovered this resident trying to take her nighttime medications that s/he did not take form the night before. MT intervened and took medications and gave s/he the morning medications."

"Order for Citalopram 10mg tablet by mouth every day for depression, Carbidopa-Levodopa 25-100 1 tablet by mouth 3 times daily at 10:00am, 2:00pm pm and 8:00pm and Trazadone 50 mg 1 tablet by mouth every night at bedtime.

In an interview at 11:40 am Staff 1 (Executive Director) stated S/he was aware of the incident with Resident 5 and medication being left in his/her room. S/he stated the incident was reported to Adult Protective Services. S/he stated the situation has since been resolved.

In an interview at 11:15am Staff 2 (MT) stated that Residents 5 medication should not have been left in his/her room, staff are to watch resident take medication then log in system. She/he stated when s/he found the pills in Residents room she/he reported it to the RN right away.

The above information was shared with Staff 1 (ED) on 04/30/24. She/he acknowledged the findings.

It was confirmed the facility failed to ensure staff visually observe residents take medications.  

VPOC: ED reported the facility has a mandatory 4-hour MT training program for all staff that now coverers administering medications that started at the end of March 2024. ED reports that only four MTs still need to complete the training program. ED reports that all new MTs are now taking class and going over the medication training navigator first thing. ED and RN have been sitting down with each MT one on one for additional training. ED and RN are doing daily clinicals where they are looking at MARs and medication orders to audit for any missed meds or meds that were not passed. The facility is following a new triple check system where if a MT is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left.

Based on record review and interview, conducted during a site visit on 04/30/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled Resident (#1). Findings include, but are not limited to:  

During a review of Resident 1's MAR dated 12/01/23 through 01/31/24, observation notes dated 12/02/23 through 01/31/24, incident report dated 01/30/24, incident investigation report dated 01/3/24, and Physicians orders the following deficiency was identified:

Resident 1 was prescribed Ins Glargine 100-U/ML (Lantus pen), inject 15 units subcutaneously every morning related to type 2 diabetes on 12/26/23.

The MAR indicated Resident 1 had been administered 15 units of Lantus twice daily at 8:00am and 11:00am starting 12/2/7/23 through 01/30/24. MAR indicates the order had been entered in twice. No other discrepancies found regarding Lantus.

Observation notes indicate on 01/30/24 RN note-MED Error, "Resident 1 began taking 15 units of Lantus in the AM on 12/12/23. On 12/2623 another dose was added, by RN who is no longer here, of 15 units Lantus at 8:00am. Since 12/27/23 Resident 1 has been getting 15 units of Lantus at 8:00am and 11:00am." Clarification from PCP on 01/29/24 indicates that Resident 1 is supposed to be getting 15 units once daily in the AM. Resident placed on alert charting.

Incident report and incident investigation report dated 01/30/24 indicate that "New RN who had only been here 1 day entered the duplicate order". On 12/26/23 a duplicate order for insulin was entered into MAR From 12/26/23 through 1/30/24 resident received 2 doses of Lantus 15 units in the AM, one dose at 0800 and one dose at 11am."

In an interview at 11:40 am Staff 1 (Executive Director) stated S/he was not present at the time of the incident and the ED at the time is no longer with employed with the company. S/he stated the new RN was auditing Residents 1 medication when the mistake was found. S/he stated the incident was reported to Adult Protective Services. S/he stated the situation has since been resolved.

In an Interview at 12:43 pm Resident 1 stated she/he did not recall the incident in December and January regarding his/her insulin but has been receiving their scheduled medications at this time.

The above information was shared with Staff 1 (ED) on 04/30/24. She/he acknowledged the findings.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed for Resident 1.  

VPOC: ED reported the facility has a mandatory 4-hour MT training program for all staff that now coverers administering medications that started at the end of March 2024. ED reports that only four MTs still need to complete the training program. ED reports that all new MTs are now taking class and going over the medication training navigator first thing. ED and RN have been sitting down with each MT one on one for additional training. ED and RN are doing daily clinicals where they are looking at MARs and medication orders to audit for any missed meds or meds that were not passed. The facility is following a new triple check system where if a MT is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located.