§483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.
§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.
§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-
§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.
§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and
§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
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Observations:
Based on review of select facility policy and controlled drug shift count records, observation, and staff interviews, it was determined that the facility failed to implement procedures for reconciling and accounting for the use and administration of controlled drugs on three of five medication carts reviewed (3rd high, 3rd low, and 2nd).
Finding include:
A review of facility policy "Controlled Medication" last reviewed by the facility February 5, 2024, indicated that the policy is to ensure appropriate management and accounting of all controlled medications. All controlled medications will be counted by the on-coming and off-going licensed nurse at the change of each shift. After verification of the accuracy of the controlled substance count, both nurses will sign the Narcotic and Controlled Drug Record on the line corresponding with the appropriate date and shift.
Observation of medication administration pass, on February 14, 2024, at approximately 8:25 AM, revealed Employee 5, Licensed Practical Nurse (LPN), was completing med pass on the 3rd floor high side medication cart. Upon review of the narcotic count records, entitled "count form", it was revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the counts of controlled drugs in the respective medication cart on February 11, 2024 and February 13, 2024. Interview with employee 5 (LPN), confirmed the observation and acknowledged the licensed nurse are expected to sign at change of shift.
A review of the narcotic count records, entitled "count form", on February 14, 2024, at approximately 8:38 AM, revealed Employee 6, Licensed Practical Nurse (LPN), on the 3rd floor low side medication cart. It was observed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following dates to verify completion of the counts of controlled drugs in the respective medication cart: January 21, 2024, and February 2, 2024. Interview with employee 6 (LPN), confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift.
A review of the narcotic count records, entitled "count form", on February 14, 2024, at approximately 12:50 PM, revealed Employee 7, Licensed Practical Nurse (LPN), on the 2nd floor medication cart. It was discovered that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify counts of controlled drugs in the respective medication cart: January 29, 2024. Interview with employee 7 (LPN), confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift.
Interview with the Assistant Nursing Home Administrator (Asst. NHA) on February 15, 2024, at approximately 11:10 AM, confirmed the observation, and that it is his expectation that nursing staff signs the narcotic count records, entitled "count form", at change of shift, and that the facility failed to implement procedures for accounting for the controlled drugs.
28 Pa Code 211.12 (d)(3)(5) Nursing services.
28 Pa. Code 211.9 (k) Pharmacy Services
| | Plan of Correction - To be completed: 04/15/2024
F 0755
Elements detailing how the facility will correct the deficiency as it relates to the individual residents. Documentation related to on-coming and off-going nurses who failed to sign the Narcotic and Controlled Drug Record forms on 01/21/2024, 01/29/2024, 02/02/2024, 02/11/2024, 02/13/2024 throughout the Facility, cannot be retroactively rectified. Narcotic counts were completed during the DOH on-site survey and controlled drugs were found to be present and accounted for.
Indicate how the facility will act to protect residents in similar situations. 100% of the active Narcotic and Controlled Drug Record forms have been reviewed in the facility. No other missing licensed nurse signatures were identified during the audit.
The measures the facility will take or the system it will alter to ensure that the problem does not reoccur. The Facility Clinical Coordinator or designee will provide re-education to licensed nurses regarding the Facility "Controlled Medication" policy to assure management and accounting of in-use controlled medications.
How the facility plans to monitor its performance to make sure that solutions are sustained. Clinical Directors or designee(s) will review Narcotic and Controlled Drug Record forms every day shift. The DON or designee will be notified immediately with any missing signatures identified.
Facility evening and night shift RN Supervisors or designee(s) will review 100% of the Narcotic and Controlled Drug Record forms every evening and night shift. The DON or designee will be notified immediately with any missing signatures identified.
Results of the daily reviews will be reviewed by the Quality Assurance Performance Improvement committee to determine if the process is effective or requires revision.
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