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Match this deficiency with the proper Plan of Correction.
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.
| Deficiency Type / Section Number | DEFICIENCIES | PLAN OF CORRECTIONS (POCs) |
|---|---|---|
| Type A 05/02/2015 Section Cited 87465(a)(5) | 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 05/21/2015 Section Cited 87465(h)(4)(5) | 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 05/21/2015 Section Cited 87465(i) | 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 05/05/2015 Section Cited 87411(a) | 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 05/15/2015 Section Cited §1569.69 | §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. |
In the medication room, resident medications are kept in:
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.
True or False:
The LPA observed medications for R1 and R1 was still out of medication, but staff was able to produce documentation that the medication was requested to be refilled.
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.
True or False:
The wellness director was present when the loose medications were removed from the cubbies.
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.
