27. Unannounced Visit: Medication Documentation

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Facility Type: 740 (RCFE)

Investigation Findings
Licensing Program Analyst (LPA) conducted an unannounced Case Management – Annual Continuation visit and initially met with med-tech. Administrator arrived shortly after the visit began. The LPA is continuing the Annual Required visit that was initiated on 4/27/15.

During the 4/27/15 inspection, the LPA observed the medication room and met with Staff #1 (S1). In the medication room, resident medications are kept in labeled trays stored in locked medication carts or in clear cubbies with the residents’ names. While reviewing medications with S1, the LPA observed loose medications in at least nine resident cubbies. S1 had no explanation as to why there were loose medications in the cubbies. When the LPA stepped away from the room momentarily, S1 admitted to disposing of some loose medications without a witness or logging the medications in the resident records. During today’s visit, the LPA observed all the remaining loose medications removed from the cubbies. Wellness Director was unsure if these medications were logged when destroyed as she was not present when they were removed.

During the medication review, the LPA observed Resident #1 to be out of a OTC medication with no discontinued order in file. S1 said there was no record from the prior staff that R1 was out of this medication. The Medication Administration Record (MAR) reflected the medication was given to R1 during the AM medication pass. The LPA inquired with Staff #2 (S2) if R1 received this medication but due to medication procedure utilized by S2, S2 was unable to determine if this medication was administered to R1 as the medications were poured by the Night time med tech and S2 just passed the pre-poured medications without checking the MAR for acurracy. S2 informed the LPA S2 initialled the MAR for the resident before passing the medications and does not normally bring the MAR with S2 when passing medications. The LPA inquired with S1 regarding the facility policy when a resident runs out of medication.

Deficiency Type /
Section Number
Type A
Section Cited
87465(a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.
R1 has been out of a medication since at least 4/27/15 and there is no record of the staff requesting a refill.
The administrator shall ensure that this medication for R1 is refilled and submit proof to CCL by 5/2/15.
Type A
Section Cited
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
During the 4/27/15 visit, the LPA observed at least 9 resident cubbies with loose medications out of their original containers. During today's visit, the LPA observed all the loose medications to be removed.
During today's visit, the LPA observed the loose medications to be removed. The administrator shall submit proof of additional training for all med techs regarding medication management to CCL by 5/21/15.
Type B
Section Cited
87465(i) Incidental Medical and Dental Care Services. When prescription medications must be destroyed, specific procedures must be followed and itemized records must be kept for a minimum of three years.
Medications were destroyed by S1 without being witnessed or recorded in the resident records.
The administrator shall submit proof of additional training for all med techs regarding medication management to CCL by 5/21/15.
Type B
Section Cited
87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.
The LPA was informed that the Meadow's dementia unit was short one staff due to an employee quitting and staff did not respond timely to resident signal system request.
The administrator shall submit a plan to CCL on how they will address staffing issues due to unexpected changes; i.e., care staff quitting or when care staff is needed in another wing to ensure all the residents' needs are met. This plan needs to be submitted to CCL by 5/5/15.
Type B
Section Cited
§1569.69 Employees assisting residents with self-administration of medication; training requirements.
Med techs are not following the procedure regarding providing assistance of medications and the medication documentation system and ensuring that all the prescribed medications are being administered and refilled when necessary.
The administrator shall submit proof of additional training for all med techs regarding medication management, along with a new plan regarding medication assistance to CCL by 5/21/15.

During today’s visit, the LPA observed medications for R1 and R1 was still out of the medication from 4/27/15. Staff was unable to find documentation that the medication was requested to be refilled. The MAR for the rest week including today indicated by staff initials that the medication was administered.

During the physical plant tour on 4/27/15, the LPA tested the signal system in room 203. The LPA waited for approximately 15 minutes with no response. Staff member who was present during the tour inquired and informed the LPA that the staff assigned to this wing was assisting another staff with a resident who needed a two-person assist.

Exit Interview Conducted / Appeal Rights Discussed & Provided / A Copy of the Report Issued with deficiency observed during today’s visit.


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