Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in five of seven client records.
Client #2 was admitted on October 31, 2024, and was an active client at the time of the inspection.
The client was prescribed 100 mg of Doxycycline on October 31, 2024 that was ordered to be taken twice per day for 10 days. The client did not receive the medication as prescribed on November 1, 5 and 9, 2024, as the client did not receive the PM dose of medication on those days.
The client was prescribed 250 mg of Divalproex on October 31, 2024 that was ordered to be taken daily. The client did not receive the medication as prescribed on November 1 & 9, 2024, as the client did not receive the PM dose of medication on those days.
Client #3 was admitted on November 9, 2024, and was an active client at the time of the inspection.
The client was prescribed Triamcinolone November 9, 2024 that was ordered to be applied topically twice daily. The client did not receive the medication as prescribed on November 11, 12, 14 and 16, 2024, as the client did not receive the PM dose of medication on those days. The client did not receive the AM or PM dose of this medication on November 15, 2024.
The client was prescribed 15 mg of Remeron on November 11, 2024 that was ordered to be taken daily. The client did not receive the medication as prescribed on November 11, 12, 14, 15 & 16, 2024.
The client was prescribed 15 mg of Abilify on November 11, 2024 that was ordered to be taken daily. The client did not receive the medication as prescribed on November 11, 12, 14, 15 & 16, 2024.
Client #4 was admitted on October 26, 2024, and was an active client at the time of the inspection.
The client was prescribed 400 mg of Gabapentin on October 28, 2024 that was ordered to be taken three times per day. The client did not receive the medication as prescribed on November 5, 2024, as the client did not receive the 2: 00 PM dose of medication on this day.
The client was prescribed 30 mg of Buspirone on October 27, 2024 that was ordered to be taken three times daily. The client did not receive the medication as prescribed on November 5, 2024, as the client did not receive the 2:00 PM dose of medication on this day.
Client #5 was admitted on October 25, 2024 and discharged on November 12, 2024.
The client was prescribed 3mg of Melatonin on October 25, 2024 that was ordered to be taken once per day. The client did not receive the medication as prescribed on October 26 and November 1, 2024.
The client was prescribed 50 mg of Melatonin on October 25, 2024 that was ordered to be taken once per day. The client did not receive the medication as prescribed on October 26 and November 1, & 9, 2024.
Client #6 was admitted on October 24, 2024 and discharged on November 12, 2024.
The client was prescribed Triamcinolone October 31, 2024 that was ordered to be applied topically twice daily. The client did not receive the medication as prescribed on November 5 & 7, 2024, as the client did not receive the PM dose of medication on those days.
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Plan of Correction
The medical assistant will retrain the medication technicians on the procedure for submitting observed medications in the EHR by 12/6/24. This training will ensure each medication that is not taken by the client is documented with the reason why the dose was missed, as well as a note providing further information on the missed medication. Any qualified staff member who is observing the medication pass is to complete this task before leaving the medication room. The medical assistant will audit the medication logs to ensure that there are no medications are listed as missed without the proper documentation. |