Print Inspection: PYGQ

Based on interview, observation, and record review, conducted during a site visit on 03/25/24, it was confirmed the facility failed to have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician for 3 of 3 sampled residents (#2, 3, and 4). Findings include, but not limited to:

During separate interviews, Staff 5 (ED) stated sometimes there were insurance issues with the pharmacy which could delay medications. Staff 4 (MT) stated the fridge temperatures were checked regularly, usually by the NOC shift and documented on the fridge log or med pass sheets. S/He stated sometimes there were delays with the pharmacy delivering medications. S/He also stated medications should be re-ordered 7 days before the med runs out. Staff 2 (Supervisor) stated MT's were dating and initialing bubble packs if they were not popped on the current date.

CS observed the temperature log on the fridge was documented on daily. Bubble packs were initialed and dated.

A review of Resident 2's September 2023 MAR and progress notes indicated the following:

·On 09/16/23 s/he did not receive his/her 5pm scheduled Ketotifen 0.025% OP 5ML OTC (Zaditor) due to  "med not here from pharmacy".

·On 09/18/23 s/he did not receive his/her 10am scheduled Vitamin D3 1000IU Softgel due to  "med not here from pharmacy".

A review of Resident 3's September 2023 MAR and progress notes indicated the following:

·On 09/19/23 s/he did not receive his/her 5pm scheduled Silver Sulfadiazine 1% Cream (Silvadene) due to  "med not here from pharmacy".

·On 09/29/23 and 09/30/23 s/he did not received his/her 8am scheduled Vitamin C 500MG Tab due to  "med not here from pharmacy".

A review of Resident 4's September 2023 MAR and progress notes indicated the following:

·On 09/22/24 s/he did not receive his/her 9am scheduled Amlodapine Tab 5MG due to  "med not here from pharmacy".

The findings were reviewed with and acknowledged by Staff 1 (Behavior Support Specialist) on 03/25/24.

It was confirmed the facility failed to have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.

Verbal plan of correction: Facility has had ongoing med tech training around medication administration and ordering medications. Med room audits are being done weekly and as needed by the director of nursing. Daily audits of the MAR is being done by supervisor.