Initial Comments:
A focused fundamental survey was conducted April 13 and 14, 2023 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 four and the sample consisted of two individuals. One deficiency was identified as a result of the survey.
Plan of Correction:
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on staff interview and incident report review, it was determined the facility failed to ensure three individuals' medications were administered without error. (Individual #1, Individual #2 and Individual #3)
Findings included:
A. Individual #1
1. On December 10, 2022 and February 11, 2023, Individual #1's ear drops were omitted.
2. Flonase nasal spray was omitted for thirty days. September 1, 2022 -September 30, 2022
B. Individual #2
1. On June 25, 2022, Individual #2's Buspar was omitted at 4:00 p.m.
C. Individual #3
1. On December 18, 2022, Alesse 28 was omitted.
D. The above-referenced errors resulted in a total of 34 medication administration errors, from June 25, 2022 to February 11, 2023.
E. Interview with the Program Director on April 14, 2023, at 9:00 a.m., and documentation review, indicated the above-referenced individuals did not experience any ill effects as a result of these medication errors.
F. Interview with the Program Director on April 14, 2023, at 9:00 a.m., confirmed the above-mentioned findings that the facility failed to administer three individuals' medications without error.
Plan of Correction:With regard to Item A-1, Individual #1's Debrox ear drops were omitted on December 10, 2022, and February 11, 2023. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List, which includes specifically double checking the MAR to ensure that all medications are administered for that time/day. Staff was also disciplined according to agency policy and completed a supervised Med Practicum.
With regard to Item A-2, Individual #1's Flonase nasal spray was omitted for a 30-day period from September 1, 2022, thru September 30, 2022. Flonase nasal spray was inadvertently discontinued from the Medication Administration Record for the month of September. Staff committing the error was counseled by the ICF Health Service Supervisor on ensuring accuracy when discontinuing medications from the Medication Administration Record. Staff was also disciplined according to agency policy.
With regard to Item B-1, Individual #2's Buspar was omitted on June 25, 2022. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List. Staff was also disciplined according to agency policy and completed a supervised Med practicum.
With regard to Item C-1, Individual #3's Alesse 28 was omitted on December 18, 2022. Omission occurred due to an additional medication cassette, which did not contain Alesse 28, being in the medication room. Staff committing the error was retrained by the ICF Supervisor on the ICF/ID Medication Administration Plan and Procedures and the Medication Pass Check List. Staff was also disciplined according to agency policy and completed a supervised Med Practicum. In addition, the ICF Health Service Supervisor counseled health service staff on the importance of removing additional medication cassettes until ready for use.
In response to the above medication errors, a retraining will be conducted on April 26, 2023, with all health service staff. This training will be provided by the ICF Health Service Supervisor. These interventions will benefit Individual #1, Individual #2, Individual #3 and all individuals in the facility by assuring that all medications are administered according to the physician's orders. Effectiveness of the interventions will be evidenced by no further incidents of individuals not receiving medications as prescribed. The Troy ICF/ID Health Service Supervisor and ICF/ID Supervisor will have overall responsibility for the monitoring and effectiveness of these interventions.
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