The facility failed to maintain an effective system for receiving, documenting, and reconciling controlled narcotics, resulting in missing oxycodone/APAP and hydrocodone/APAP for two residents with chronic pain and major depressive disorder. Pharmacy records showed full quantities of controlled medications were delivered, but medication cards and count sheets for significant portions of these drugs could not be located, and the receiving logs did not reflect the deliveries. For one resident, the controlled drug count sheet showed doses documented as given that were not recorded on the MAR, while the resident reported taking only one dose and a CMA reported their signature had been forged on the count sheet. For the other resident, reconciliation of count sheets and packing slips revealed 30 tablets unaccounted for, with incomplete count sheets for the month. Staff interviews showed inconsistent reconciliation practices and acknowledged a period without a full-time DON during which these discrepancies occurred.
A resident with orders for levothyroxine for hypothyroidism and divalproex for dementia did not receive multiple scheduled doses because the medications were not available in the building. Review of the MAR showed several early-morning levothyroxine doses and morning divalproex doses marked as held due to unavailability or lacking documentation. CMAs reported that medications were ordered when supplies were low and that unavailable medications were left on the MAR while notifying nursing staff, pharmacy, and the DON, while leadership stated medications should be reordered earlier and STAT if needed. These discrepancies in practice led to repeated missed doses of the resident’s prescribed medications.
The facility failed to accurately document and account for controlled medications, including Norco, Ativan, and tramadol, for several residents. For one resident receiving PRN Norco for pain, the narcotic count sheets repeatedly showed more doses signed out than were recorded as administered on the MAR, with no documentation that the extra tablets were destroyed. For another resident with a nightly Ativan order, the narcotic record often showed doses as given while the MAR documented refusals, and there were no destruction notations for the refused tablets; on one occasion the MAR showed a dose given with no corresponding narcotic sign-out. A third resident’s narcotic record showed tramadol doses administered on a day when the MAR showed none given and no destruction documented. CMAs and nursing staff acknowledged that the records were inaccurate and that refused controlled medications were not consistently brought to a nurse for joint destruction and co-signature as required.
A resident with emphysema and heart failure had an order for oxycodone 10 mg PO every six hours. Facility policy required two staff signatures when wasting narcotic medications, but documentation on the controlled drug record showed that one oxycodone tablet was wasted with only a single staff signature. An LPN and the infection preventionist both stated that two staff members must sign when a narcotic is wasted, confirming that the documented wasting did not follow facility policy, in a setting where multiple residents were receiving medications.
A resident with generalized pain, gout, and liver cirrhosis had a care plan and physician order for oxycodone 5 mg every six hours as needed, but did not receive the ordered oxycodone on an overnight shift when pain was reported as severe. The MAR showed oxycodone was given on earlier shifts, yet there was no documentation of administration overnight. The resident reported being told there was no nurse available to give narcotics and was instead offered Tylenol, which they refused due to a liver condition and prior instructions from a transplant physician. The overnight LPN stated they were the only nurse on duty, refused to accept the narcotic lockbox keys, did not know where the keys were, and therefore did not administer oxycodone when requested. Facility leadership later confirmed that medications were to be administered as ordered and that the resident’s oxycodone should have been provided.
A resident who had been receiving furosemide 60 mg PO daily in the hospital was admitted with discharge instructions to continue that dose, but the facility’s physician order was entered as only 40 mg PO daily. The resident, who had moderate cognitive impairment and was documented as receiving a diuretic, reported the dose discrepancy, and the ADON later confirmed that the hospital discharge order specified 60 mg daily and that a nurse had mistakenly entered the lower dose.
A resident with thrombocytopenia had a physician’s order for nightly eltrombopag olamine 50 mg, but the medication was not administered on two consecutive days. The MAR documented missed doses, while nurse notes alternately indicated the pharmacy would not dispense the drug and that staff were waiting on delivery, even though an incident report later showed the medication had been received and locked in the narcotic box. One CMA reported being unable to find the medication, marked it as not in the building when a family member requested it, and did not escalate to the ADON as expected, while another CMA could not recall if the medication was given. The ADON stated that the process when a medication cannot be found is for the medication aide to notify the nurse and for the nurse to notify the physician.
A resident did not receive multiple prescribed medications as ordered, with several missed doses documented as blanks on the MAR and no explanations provided. Facility staff confirmed that these medications were not administered or documented according to policy.
A resident with heart failure, hypertension, and renal insufficiency did not receive Lasix at the physician-ordered times on multiple occasions. Audit reports showed several doses were administered late, and staff interviews revealed inconsistent adherence to the facility's medication timing protocol. The facility did not ensure medications were given as ordered, resulting in a deficiency related to timely medication administration.
The facility did not fully transcribe and administer hospital discharge medication orders for a resident with multiple diagnoses, omitting key medications at admission. Additionally, another resident did not receive prescribed pain medication as ordered, with several doses held without proper documentation or communication, despite reports of significant pain.
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