Initial Comments:
A focused fundamental survey visit was completed on October 17 and 18, 2024.
The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was five, and the sample consisted of
four individuals.
Plan of Correction:
483.460(k) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The facility must have an organized system for drug administration that identifies each drug up to the point of administration.
Observations:
Based on observations, and interview with the facility and administrative staff, the facility failed to have an organized system for drug administration that identifies each drug up to the point of administration for four of four sample individuals observed during morning medication administration. This practice is specific to Individuals #1, #2, #3 and #4.
Findings include:
Observations of the morning medication administration on 10/17/2024 between 7:20 AM until 8:35 AM revealed the following;
- Staff verbally prompted Individual #1 to come to the medication closet between the kitchen and dining room. Staff proceed to remove a medication cup from the closet that had pre-poured medication in it and handed it to Individual #1. Individual #1 took the medication and swallowed the medication.
-At 7:25 AM, Staff then called Individual #3 to the medication area to take his medications. Staff pulled out a medication bin and a medication cup with medication in it. The cup fell to the floor, spilling the medication on the floor. Staff picked up the medication from the floor and discarded. Staff told Individual #3 that he would need to wait until later to get his medications.
- Staff proceed to remove another bin from the medication closet and took it to Individual #4, who was seated on the couch in the living room. Staff removed a medication cup with pre-poured medications, from this bin that contained all of Individual #4's medication. Staff dumped the pre-poured medication into a cup of applesauce and handed the cup of applesauce and medications to Individual #4. Individual #4 independently ate his medications in the applesauce.
- Staff then went back to the medication closet and removed another bin with medication in it and verbally prompt Individual #2 to sit at the dining room table. Staff then took
Indvidual #2's blood pressure. After taking Indvidual #2's blood pressure, staff went to remove a medication cup from the medication bin and it was observed that this medication cup was on its side and there were loose medications lying on the bottom of this bin. Staff proceed to scoop up the loose medication back into the medication cup and hand the cup to Individual #2. Individual #2 took the medication and drank water to assist with swallowing the medication.
Interview with the direct care staff administering the medication on 10/17/2024 at approximately 7:31 AM confirmed the this staff she pre-poured all the Individuals medication prior to administration and was unable to identify the drugs she administered.
Interview with the Director of IDD/ICF services on 10/18/2024 at approximately 9:30 AM confirmed that staff should not pre-pour medication for the Individuals. This interviewee confirmed that Individuals should have participated in there medication administration to ensure medications are identify up to the point of administration.
Plan of Correction:
CE 1
Staff responsible for medication administration on 10/17/24 were immediately sent to Training Director following morning routine for review of proper medication administration protocols. The training reviewed that "pre-pouring" of medications is prohibited and the staff must always follow the medication administration policy.
Training records will be kept on file
Completion date: 10/17/2024
CE 2
The Training Director will hold a mandatory "all" staff training at the facility on 10/29/2024. The training will include but not limited to; review of Medication Administration policy, proper disposal of spilled medication, prohibition of pre-pouring of mediations, proper storage of mediations and following the principles of the "5 rights" for every medication administration.
Training records will be kept on file.
Completion date: 11/12/2024
CE 3 /4
Training Director will offer a review of medication observation checklist with all of the Medication Practicum Observers. The Practicum Observers will be assigned a schedule to complete observation at the home varying time and day.
The Practicum Observers will be scheduled weekly for the next two months and then monthly for an additional four months. All observations will be completed on the PA Medication Administration observer form. The observations will be forwarded to the Administrator for review. Any notes will be immediately addressed by practicum observer and noted of form. If necessary, the staff not following protocols will be given feedback and scheduled to meet for training department for further remediation.
Completion date: 4/1/2025
CE 5
Person responsible: The Administrator will review the training and audits used to monitor and correct areas of deficient practice related to citation. The Administrator will direct all corrective actions as needed to ensure compliance .
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