A resident with anxiety, dermatitis, and hypothyroidism did not consistently receive ordered medications, including Levothyroxine, Xanax, and Dupixent, as documented on the MAR. Levothyroxine doses were missed on consecutive days, with one omission unexplained and another marked as not available despite prior delivery from the pharmacy, and no provider notification was documented. A scheduled Dupixent dose was delayed due to unavailability, and a Xanax dose was missed and marked as not available even though the medication had been received, again without documented provider notification. An APRN later noted the resident experienced intermittent seizure-like activity when the morning Xanax dose was missed and stated she should have been notified of omissions. Interviews with the DNS and LPNs revealed issues with agency staff marking medications as not available, failure to verify and obtain medications from stock or pharmacy, and lack of provider notification, contrary to facility medication administration and documentation policy.
A resident with seizure disorder, dementia, and multiple comorbidities experienced repeated failures in timely medication administration and documentation. Required scheduled doses of gabapentin and acetaminophen were not documented as given at the ordered time, despite an RN later stating they had been administered. On another day, an RN documented a set of 9:00 AM medications, including anticonvulsants, antihypertensives, anticoagulant, antidepressant, and laxative, more than four hours late, while another RN administered evening anticonvulsant, analgesic, muscle relaxant, anticoagulant, sleep aid, antidepressant, and neuropathy medications more than two to three hours earlier than scheduled. One RN reported routinely delaying electronic documentation until after completing the full med pass due to EMR issues and workload, contrary to the facility’s one-hour administration window and immediate documentation standard.
The facility failed to maintain proper control and accountability of discontinued narcotic medications, resulting in missing Oxycodone and Lorazepam tablets for three residents with pain, dementia, and anxiety. Discontinued controlled drugs remained in unit narcotic lock boxes instead of being promptly removed to a secured nursing office lock box, and both the white proof-of-use sheets and matching medication packs went missing. An LPN’s narcotic audits did not include MAR review, discrepancies were adjusted to match proof-of-use sheets, and required dual nurse signatures for end-of-shift narcotic counts were missing on multiple dates. These actions and omissions violated the facility’s own controlled substance handling policy and led to unaccounted-for controlled substances.
Missing Controlled Drug Count Signatures: The facility failed to ensure shift-to-shift controlled drug counts were consistently completed for a medication cart on the South unit. The controlled drugs count record was missing 4 signatures across 2 shifts, and the DNS stated she was unaware of the omissions until the review. The facility policy required the oncoming and offgoing nurses to count controlled drugs together and document any discrepancies.
A resident with a right femur fracture had orders for PRN Oxycodone and scheduled Lyrica for pain management. Pharmacy records and proof of delivery showed that two 30-count blister packs of Oxycodone and two 30-count blister packs of Lyrica were delivered and signed for by an RN. Facility video showed the RN handing four blister packs to an LPN, who placed them on top of a hallway med cart, did not verify the quantity at hand-off, left the controlled drugs unsecured while administering another resident’s meds, and later documented receipt of only three blister packs (two Lyrica and one Oxycodone). CSDRs were completed for two Lyrica packs and only one Oxycodone pack, leaving one Oxycodone blister pack unaccounted for and demonstrating failure to follow the facility’s double-lock and immediate recording requirements for controlled substances.
A resident received two sets of medications in one evening, including another resident's medications, after an LPN placed a refused dose back in the med cart and later gave it to a NA to administer, who then gave it to the wrong resident. On another occasion, an LPN and an RN each administered medications without checking resident identification bands, relying instead on familiarity, despite facility policy requiring verification by wristband or photo and limiting medication preparation and administration to licensed staff.
The facility failed to maintain an established system for controlled substance audit and reconciliation. The DNS said audits were limited to counting narcotics on the med carts and checking expiration dates, while the yellow/pink CSDR sheets kept in binders were not used for audits. RN#4 said she only matched completed white CSDRs to the binder records and did not perform the facility audits. Surveyors flagged 12 controlled substances; 10 were present, but 2 could not be reconciled because they were not in use and were not found in the destroyed med logs. The facility policy required controlled substances to be regularly reconciled to the MAR and documentation.
The facility did not consistently document the removal and wasting of controlled substances on the CSDR for a resident, and failed to record the administration of controlled medications on the MAR for two residents. This included missing documentation for Fentanyl patches and Tramadol, despite facility policy requiring timely and accurate recording by nursing staff.
The facility did not ensure that two licensed nurses conducted the required shift count of controlled substances during the handoff of narcotic keys, resulting in missing oxycodone and incomplete, altered documentation on the Controlled Drug Inventory Sheets. An LPN received the narcotic keys without a count, and another LPN was rushed during the process, leading to discrepancies and missing records. Facility policy requiring two-nurse counts and accurate recordkeeping was not followed.
A resident with diabetes and other complex conditions missed four days of prescribed insulin after the facility failed to coordinate with the pharmacy to clarify and deliver the correct medication. The pharmacy did not fill the updated order, and nursing staff did not consistently notify supervisors or the pharmacy about the missed doses, resulting in a lapse in medication administration.
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