Print Inspection: 85OI

Based on observation, interview, and record review, conducted during a site visit on 02/06/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

In an interview, Staff 2 (Health & Wellness Director) stated the following:

- S/He held the delegations for the building since September 2023.

- Medication errors are documented through incident reports.

- Every resident has their own box with insulin and diabetic supplies that are kept together.

- Staff 6 (Med Tech) had grabbed the wrong box of insulin.

- After Staff 6's medication error, there was a corrective action put in place.

- Staff 6 is currently out on leave.

- Resident 1's physician orders have not changed since November 2023.

A review of facility's delegation records for Staff 6, dated 05/30/23 through 09/21/23, indicated Staff 6 was delegated to administer insulin for Resident 1.

During an interview, Staff 5 (Med Tech) stated the following:

-The first step in the process for administering insulin is pulling the medication up on the MAR, then performing a blood sugar check if required, read the insulin on the MAR, then pull the insulin, then check for the right person, right medication.

-If the insulin is a pen, use an alcohol wipe to wipe off the top of the pen, then pull the units of insulin required, ensure it is cleared, and then pull the amount to dose.

-Staff 5 had not heard about a resident receiving someone else's medication.

-Insulin is kept in the refrigerator in the Med Room until it's ready for use.

-Each resident has their own box of supplies including the insulin and blood testing kit. The box should contain everything staff need for each resident;

-Insulin is then kept in the med cart when it's ready to be administered.

-If there is a medication error, the first step is to notify the RN and resident's doctor right away, then staff would look through resident's MAR for any allergies, put the resident on alert charting and monitor based on what type of medication error occurred, based on the advice from RN or resident's doctor, the resident may need sent out to the ED, staff would then complete an incident report along with notifying the resident's family of the medication error.

At approximately 1:00 pm, the Compliance Specialist observed the following in the medication room:

-Insulin was stored in the refrigerator in the medication room.

-Diabetic supplies were present in the medication cart.

-Supplies were in separate containers for each resident with their names and room numbers written on labels.

In an interview, Staff 1 (Executive Director) stated the following:

-For a medication error, the facility would review what the medication error was and pull the resident into the review.

-Facility staff are directed to notify Staff 1 immediately if a resident is out of medications.

-When over the counter medications are missing, staff will go to a store and purchase the medication.

-The facility may notify resident's family to pick up medications that are not available over-the-counter, if possible.

-There was a write up for Staff 6's medication error.

In an interview, Resident 1 stated the following:

-S/He is prescribed insulin.

-S/He received medication support from the facility.

-The facility's Med Tech checks his/her blood sugar twice daily and administers the insulin if needed.

-S/He did not recall a time where s/he missed a dose of insulin or was administered another resident's insulin.

A review of Resident 1's service plan, dated 12/20/23, indicated s/he receives Lantus insulin each evening.

A review of Resident 1's physician orders, dated 10/31/23, indicated s/he is to receive 17 units of Lantus 100 unit/mL subcutaneously in the evening.

A review of Resident 1's MAR dated October 2023 indicated on 10/16/23, Lantus 100 unit/mL was not administered to Resident 1.

A review of Resident 1's Progress Notes, dated 10/01/23 to 11/30/23, indicated the following:

-On 10/16/23, Resident 1 received 17 units of the wrong insulin. "[In-Home Provider] is not worried about this due to it being long acting insulin."  

-Resident 1 was placed on alert for receiving the wrong insulin.

A review of the facility's self report, dated 10/17/23, indicated the following:

- On 10/16/23, at approximately 5:30 pm, Staff 6 administered the wrong drug and gave another resident's insulin to Resident 1;

-Staff 2, Resident 1's physician, and Resident 1's family were notified of incident; and

-Resident 1 did not have an adverse reaction to the insulin administered.

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

The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, and Staff 3 (Resident Care Coordinator) on 02/06/24.

Verbal Plan of Correction:

The facility's plan of correction is to continue with staff education and training. The facility now has an RN 40 hours a week in the building instead of the previous model of LPN oversight and RN in the building twice weekly. They will continue monthly in service meetings for Med Techs and Caregivers to go over any medication errors and have opportunities to ask questions.