Initial Comments:
A focused fundamental survey was conducted February 6-8, 2024, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was 49 and the core sample consisted of four individuals.
Plan of Correction:
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observations, review of physician's orders, and interview, it was determined that the facility failed to ensure all medications were administered without error. This applied to one of three medication administrations observed. Findings included:
A medication administration was observed on February 7, 2024, in Apartment 2 from 6:57 AM until 7:23 AM. At 7:00 AM, the licensed practical nurse (LPN) began to pour Individual #5's medications, which included ferrous gluconate tablets 324 milligrams. The ferrous gluconate label indicated to take "one tab via g-tube [gastrostomy tube] every other day." There were seven other medications poured by the LPN, all of which were labeled to be given via jejunostomy tube (j-tube). At 7:05 AM, the LPN was witnessed to crush the ferrous gluconate and then place it in a cup along with the other medications. At this time, the surveyor questioned the LPN regarding the route of the ferrous gluconate. The LPN checked the label on the ferrous gluconate packaging and the medication administration record (MAR), and then confirmed that the label and the MAR indicated that the ferrous gluconate should be given via g-tube. The LPN then stated that she would dispose of those medications and then proceeded to pour all eight medications again. The LPN was witnessed to crush the ferrous gluconate and place it in a cup marked "G." The LPN placed the other seven medications in a cup marked "J." At 7:19 AM, the LPN was witnessed to pass the ferrous gluconate via g-tube and all other medications via j-tube. At 8:05 AM, the LPN was asked how Individual #5's ferrous gluconate would have been administered if the surveyor had not intervened and brought it to their attention. The LPN responded, "I probably would have given it in the j."
Physician's orders for Individual #5 dated January 2, 2024, were reviewed on February 7, 2024, to reconcile the observed medication pass. This review revealed an order for "FERROUS GLUC TAB 324MG TAKE 1 TABLET VIA G-TUBE EVERY OTHER DAY."
An interview was completed with the assistant health services supervisor (AHSS) on February 8, 2024, at 11:07 AM. At this time, the AHSS confirmed that Individual #5's ferrous gluconate would have been administered via the incorrect route if this surveyor had not intervened and a medication error would have occurred.
Plan of Correction:On 2/7/2024, the Asst. Health Services Supervisor generated a Medication Error for wrong route.
On 2/7/2024, the Asst. Health Services Supervisor trained LPN on Protocol for transcription errors.
On or before 3/11/2024, the Asst. Health Services Supervisor or Designee will train all nurses on the Protocol for transcription errors.
On 2/7/2024 the Asst. Health Services Supervisor trained LPN on Protocol for Medication Administration.
On or before 3/11/2024, the Asst. Health Services Supervisor or Designee will train all nurses on the Protocol for Medication Administration.
On 2/13/2024, the nurse checked their assigned medication cart to ensure there were no discrepancies. The nurse will report any discrepancies to the AHSS or Designee, and appropriate follow up will be completed.
The Asst. Health Services Supervisor or Designee will check physician change of route orders weekly times four (4) weeks and then monthly times three (3) months.
The Asst. Health Services Supervisor or designee will complete a Medication Pass observation for LPN one (1) time per week for three (3) weeks and then one (1) time per month for the next three (3) months.
The Asst. Health Services Supervisor or Designee will complete four (4) Medication Pass Audits per month.
The Administrator, Health Services Supervisor and Asst. Health Services Supervisor will review Medication Pass Audits monthly for the next six (6) months to determine any trends, concerns or need for additional follow up.
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