Observations
Based on a review of client medication administration records, the facility failed to provide documentation of medication being provided as prescribed by a physician in seven of seven client records.
Client #1 was admitted on January 13, 2025 and discharged on March 14, 2025. The medication administration record (MAR) was reviewed for January, February and March 2025.
Amlodipine Besulate 10 mg was prescribed on January 28, 2025, with physician instructions to take one tablet by mouth once daily. The MAR did not include documentation that the client received the medication as prescribed on January 29 & 30, February 1, 6, 7, 8, 9, 15, 18, 20, 23, & 26 and March 4, 5, 6, 7, 11 and 13, 2025.
Gabapentin 300mg was prescribed on January 28, 2025, with physician instructions to take one capsule three times per day. The MAR did not include documentation that the client received the medication as prescribed on January 30 & 31, Febraury 1, 2, 3, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 19, 20, 22, 23, 24, 26, 27 & 28 and March 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 & 14, 2025.
Lisinopril 40mg was prescribed on January 13, 2025 and discontinued on February 20, 2025, with physician instructions to take one tablet once per day. The MAR did not include documentation that the client received the medication as prescribed on January 14, 15, 16, 17, 18, 19, 24, 28, 29 & 30, Febraury 1, 6, 7, 8, 9, 15, 18 & 20, 2025.
Losartan Potassium 50 mg was prescribed on January 28, 2025, with physician instructions to take one tablet by mouth once daily. The MAR did not include documentation that the client received the medication as prescribed on January 29 & 30, February 1, 6, 7, 8, 9, 15, 18, 20, 23 & 26 and March 4, 5, 6, 7, 11 & 13, 2025.
Metoprolol Tartrate 25 mg was prescribed on January 28, 2025, with physician instructions to take one tablet by mouth once daily. The MAR did not include documentation that the client received the medication as prescribed on January 29 & 30, February 1, 6, 7, 8, 9, 15, 18, 20, 21, 23 & 26 and March 4, 5, 6, 7, 11, 13 & 14, 2025.
Mirtazapine 15 mg was prescribed on January 28, 2025, with physician instructions to take one tablet at bedtime daily. The MAR did not include documentation that the client received the medication as prescribed on January 30 & 31, February 3, 6, 7, 8, 9, 10, 12, 14, 15, 16, 18, 19 &20, 2025.
Amoxicillin / Clavulanic Acid 875/125 mg was prescribed on February 10, 2025, with instructions to take one tablet every 12 hours. The MAR did not include documentation that the client received the medication as prescribed on February 14, 15, 16, 18, 19, 20, 21, 23, 24, 26, 27 & 28 and March 2, 3, 4, 5, 6, 7, 9, 11, 12, 13 & 14, 2025.
Azithromycin 250 mg was prescribed on February 10, 2025, with physician instructions to take one tablet by mouth once daily. The MAR did not include documentation that the client received the medication as prescribed on February 15, 18, 20, 21, 23 & 26 and March 4, 5, 6, 7, 11, 13 & 14, 2025.
Bisoprolol Fumarate 5 mg was prescribed on February 17, 2025, with physician instructions to take one tablet by mouth once daily. The MAR did not include documentation that the client received the medication as prescribed on February 18, 20, 21, 23 & 26 and March 4, 5, 6, 7, 11, 13 & 14, 2025.
Latanoprost Eye Drops .005% was prescribed on February 26, 2025, with physician instructions to drop into left eye at bedtime daily. The MAR did not include documentation that the client received the medication as prescribed on February 27 & 28 and March 3, 5, 9, 12 & 14, 2025.
Lovastatin 40 mg was prescribed on February 17, 2025, with physician instructions to take one tablet at bedtime daily. The MAR did not include documentation that the client received the medication as prescribed on February 18, 20, 23, 24, 26, 27 & 28 and March 2, 3, 5, 9, 11, 12 & 14, 2025.
Client #2 was admitted on January 13, 2025 and discharged on March 10, 2025. The medication administration record (MAR) was reviewed for January, February and March 2025.
Advair 115/21 mg was prescribed on January 17, 2025, with physician instructions to take two puffs twice per day. The MAR did not include documentation that the client received the medication as prescribed on January 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 & 31, February 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 19, 20, 21, 22, 23, 26, 27 & 28 and March 3, 4, 5, 6, 7, 8, 10, 11 & 12, 2025.
Fluoxetine 20 mg was prescribed on March 5, 2025, with physician instructions to take one capsule once daily. The MAR did not include documentation that the client received the medication as prescribed on March 7, 9, 11 & 12, 2025.
Mirtazapoine 30 mg was prescribed on March 5, 2025, with physician instructions to take one tablet daily at bedtime. The MAR did not include documentation that the client received the medication as prescribed on March 5, 10, 11 & 12, 2025.
Client #3 was admitted on January 15, 2025 and discharged on February 18, 2025. The medication administration record (MAR) was reviewed for Janurary and February 2025.
Bromocriptine 5 mg was prescribed on January 15, 2025, with physician instructions to take one capsule once daily at bedtime. The MAR did not include documentation that the client received the medication as prescribed on January 15-31, February 1, 2, 3, 4, 5, 6, 7, 8, 15, 16 & 18, 2025.
Buproprion 150 mg was prescribed on January 17, 2025, with physician instructions to take one tablet every morning. The MAR did not include documentation that the client received the medication as prescribed on January 17-31, February 1, 2, 3, 4, 5, 6, 7, 9, 14, 15 & 16, 2025.
Duloxetine 60 mg was prescribed on January 17, 2025, with physician instructions to take one capsule twice daily. The MAR did not include documentation that the client received the medication as prescribed on January 17-31, February 1-18, 2025.
Lithium Carbonate 450 mg was prescribed on January 17, 2025, with physician instructions to take one capsule twice daily. The MAR did not include documentation that the client received the medication as prescribed on January 17-31, February 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 2025.
Olanzapine 15 mg was prescribed on January 17, 2025, with physician instructions to take one tablet once daily at bedtime. The MAR did not include documentation that the client received the medication as prescribed on January 17-31, February 1, 2, 3, 4, 5, 6, 7, 8, 15, 16, 2025.
Ropinirole 1 mg was prescribed on January 17, 2025, with physician instructions to take one tablet every evening. The MAR did not include documentation that the client received the medication as prescribed on January 17-31, February 1, 2, 3, 4, 5, 6, 7, 8, 15, 16, 2025.
Valacyclovir 1 gm was prescribed on January 17, 2025, with physician instructions to take one tablet threee times daily. The MAR did not include documentation that the client received the medication as prescribed on January 17-31, February 1-18, 2025.
Vraylar 1.5 mg was prescribed on January 17, 2025, with physician instructions to take one capsule once daily. The MAR did not include documentation that the client received the medication as prescribed on January 17-31, February 1, 2, 3, 4, 5, 6, 7, 9, 14, 15, 16, 2025.
Doxycycline 100 mg was prescribed on February 7, 2025, with physician instructions to take one capsule twice daily for 10 days. The MAR did not include documentation that the client received the medication as prescribed on February 8, 9, 14, 15, 16 & 17, 2025.
Lithium Carbonate 450 mg was prescribed on January 17, 2025, with physician instructions to take one capsule twice daily. The MAR did not include documentation that the client received the medication as prescribed on January 17-31, February 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 2025.
Fluconzaloe 150 mg was prescribed on February 7, 2025 with physician instructions to take one tablet by mouth for two days. The MAR does not indclude documentation that the client ever received this medication.
Client #4 was admitted on December 23, 2024 and discharged on March 7, 2025. The medication administration record (MAR) was reviewed for Janurary, February and March 2025.
Triamcinolone Cream .1% was prescribed on January 9, 2025, with physician instructions to apply twice daily. The MAR did not include documentation that the client received the medication as prescribed on January 9-31, February 1-28 and March 1-7, 2025. There was no documentation that any of this medication was administered.
Fluoxetine 20 mg was prescribed on February 13, 2025, with physician instructions to take one capsule every morning. The MAR did not include documentation that the client received the medication as prescribed on February 13-28 and March 1-7, 2025. There was no documentation that any of this medication was administered.
Symbicort 80/4.5 mg was prescribed on February 13, 2025, with physician instructions to inhale tow puffs twice daily. The MAR did not include documentation that the client received the medication as prescribed on February 13-28 and March 1-7, 2025. There was no documentation that any of this medication was administered.
Client #5 was admitted on November 26, 2024 and discharged on March 7, 2025. The medication administration record (MAR) was reviewed for Janurary, February and March 2025.
Buprenorphine-Naloxone 8/2 mg was prescribed on January 3, 2025, with physician instructions to dissolve one film sublingually once daily. The MAR did not include documentation that the client received the medication as prescribed on January 1, 2, 3, 4, 6, 8, 9. 10, 12, 15, 16, 18, 19, 21, 24, 25, 27, 30, & 31, February 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 & 28, 2025. There was no documentation that any of this medication was administered.
Fluoxetine 40 mg was prescribed on January 2, 2025, with physician instructions to take 2 capsules by mouth every morning. The MAR did not include documentation that the client received the medication as prescribed on January 3, 4, 5, 6, 7, 8, 10, 12, 16, 18, 19, 20, 21, 22, 24, 25 & 30, February 1, 4, 6, 7, 9, 10, 15, 17, 20, 22, 23, 25 & 30 and March 3, 5, 6 & 7, 2025.
Gabapentin 100 mg was prescribed on January 2, 2025, with physician instructions to take 1 capsule by mouth three times a day. The MAR did not include documentation that the client received the medication as prescribed on January 4-19 & 21-31, February 1-17 & 19-28 and March 3-7, 2025.
Hydroxyzine 50 mg was prescribed on November 26, 2024, with physician instructions to take 1 capsule by twice daily - morning and bedtime. The MAR did not include documentation that the client received the medication as prescribed on January 1, February 26, 27 & 28 and March 3, 5, 6, 7, 8, 9, 10, 11 & 12, 2025.
Prazosin 1 mg was prescribed on January 2, 2025, with physician instructions to take 1 capsule by mouth twice daily. The MAR did not include documentation that the client received the medication as prescribed on January 3, 4, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19, 20, 21, 24, 25, 26, 27 & 28, February 1-20 & 22, 23, 24, 25, 26, 27, & 28 and March 1, 3, 5, 6 &7, 2025.
Oseltamivir 75 mg was prescribed on February 4, 2025, with physician instructions to take 1 capsule by mouth twice daily until February 9, 2025. The MAR did not include documentation that the client received the medication as prescribed on February 4-9, 2025.
Prednisone 20 mg was prescribed on February 10, 2025, with physician instructions to take 1 tablet daily. The MAR did not include documentation that the client received the medication as prescribed on February 15, 17, 18, 20, 21, 22, 23, 25, 26 & 28 and March 3, 5, 6 & 7, 2025.
Amoxicillian/Clavulanate 875/125 mg was prescribed on February 10, 2025, with physician instructions to take one tablet twice daily. The MAR did not did not include documentation that the client received the medication as prescribed on February 11-28 and March 2-7, 2025.
Famotidine 40 mg was prescribed on February 26, 2025, with physician instructions to take one tablet daily. The MAR did not did not include documentation that the client received the medication as prescribed on February 28 and March 3 & 7, 2025.
Client #6 was admitted on January 10, 2025 and discharged on March 12, 2025. The medication administration record (MAR) was reviewed for Janurary, February and March 2025.
There were no MARs documented for January, February and March 2025. The MARs were unable to be located by facility staff. It was confirmed that client #6 was prescribed medications as there were medication inventories documented; however, there were no corresponding MARs to documented what medications client #6 received.
Client #7 was admitted on January 16, 2025 and discharged on February 28, 2025. The medication administration record (MAR) was reviewed for Janurary and February 2025.
Doxepin 100 mg was prescribed on January 29, 2025, with physician instructions to take one capsule at bedtime. The MAR did not did not include documentation that the client received the medication as prescribed on January 30-31, February 3, 5, 6, 7, 8, 15, 16, 20, 22, 23, 24, 25, 27 & 28, 2025.
Famotidine 20 mg was prescribed on January 29, 2025, with physician instructions to take one tablet daily at bedtime. The MAR did not did not include documentation that the client received the medication as prescribed on January 30-31 and February 3, 5, 6, 7, 8 & 12-28, 2025.
Metformin 500 mg was prescribed on January 29, 2025, with physician instructions to take one tablet twice daily. The MAR did not did not include documentation that the client received the medication as prescribed on January 30-31 and February 5, 6, 7, 8, 9, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 27 & 28, 2025.
Omeprazole 40 mg was prescribed on February 12, 2025, with physician instructions to take one tablet once daily. The MAR did not did not include documentation that the client received the medication as prescribed on February 13, 14, 20, 21, 23 & 27, 2025.
These findings were discussed with facility staff during the onsite follow up inspection.
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Plan of Correction
Director of Operations will work with Chief of Staff to update medical control policy to show necessary changes in administration and documentation.
Monitor staff will be required to announce individual cohort during medication distribution. During medication distribution, staff should follow 5 'R's standard to ensure that medication compliance is addressed by all persons (staff and residents). The 5 'R's are standard healthcare practices that addressed the following; Right Patient, Right Time, Right Drug, Right Route, Right Dose. Staff must ensure that documentation is legible, accurately endorsed by required parties, and distributed in accordance with 5 R's to remain medically compliance during medication distribution. These standards as well as medication compliance checklist are posted and/or placed within each medication cart for consistent training reference points, when applicable.
During 12-8am shift, monitor staff will complete a nightly audit to ensure medication compliance is being followed. The nightly audit should consist of counting all medication within medical cart(s) and provide reconciliation audit(s) and/or report(s) to reflect current count prior to morning medication distribution call. During the nightly audit, staff should ensure appropriate documentation is updated for accurate compliance standards.
When/If any reconciliation numbers are needed during the nightly audit, staff should submit an incident report when numbers are off by the following parameters:
Regular medication (non-controlled) : +/- 5
Narcotic (controlled medication) : +/- 2
Once medication is delivered via our contractor provider, on-site staff must scan inventory documentation to medical department and management staff as this will provide direct compliance to all parties for updated medication and discontinued medication removal, if applicable.
Medical department should ensure that all discontinued medication will be removed from medication carts once notification is received. Medical department should ensure that updated accurate medication sheets are available to ensure medication compliance and accurate documentation. Medical department will complete a biweekly audit of each medication cart to ensure compliance. During the medical department's biweekly audit, medical should review reconciliation numbers are accurate, removal of discontinued medication, update of medication sheets, and documentation placement for accurate record keeping. Management staff will complete monthly internal audit to ensure medication compliance. During monthly audit, management staff will also check for inaccuracies within nightly audits from monitor staff and biweekly audits from medical department to ensure overall compliance and oversight of medication.
Passages to Recovery is hiring a Registered Nurse on 06/16/2025. The nurse will assist Director of Clinical Services, Director of Operations, and Certified Medical Assistance in regular and random audits of medication carts, review of medication passes to ensure clinical compliance.
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