Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in six of seven client records.
Client #1 was admitted on October 28, 2022 and discharged on May 3, 2023.
The client was prescribed a medication and the prescription stated that one tablet was to be taken once a day at bedtime. The medication administration records showed that the medication was not being given on November 22, 29, and 30, 2022. There was no additional documentation included indicating a reason why the medication was not given as prescribed.
The client was prescribed a medication and the prescription stated that one tablet was to be taken twice daily. The medication administration records showed that the medication was not being given on November 7, 8, 10, December 21, 2022. The documented reason for not being taken was " out of medication. "
This medication was also not given on November 9, 30, December 22, 23, 30, 31, 2022. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
The client was prescribed a medication and the prescription stated that two tablets were to be taken nightly. The medication administration records showed that the medication was not being given on November 11-21, 23-27, 29, 2022, and January 22, 2023. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one capsule was to be taken twice daily. The medication administration records showed that the medication was not being given on December 11-16, 2022. The documented reason for not being taken was " out of medication. "This medication was also not given December 17 and 18, 2022. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
The client was prescribed a medication and the prescription stated that one tablet was to be taken once daily. The medication administration records showed that the medication was not being given on December 15 and 16, 2022. The documented reason for not being taken on December 15, 2022 was " out of medication. " There was no additional documentation included indicating a reason why the medication was not given as prescribed on December 16, 2022.
The client was prescribed a medication and the prescription stated that one tablet was to be taken daily. The medication administration records showed that the medication was not being given on December 19, 22, and 23, 2022. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
The medication was also not given on December 30, 2022. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one tablet was to be taken daily. The medication administration records showed that the medication was not being given on December 16, 17, 2022, January 10-12, 14-17, 20-21, 2023. The documented reason for not being taken was " out of medication. "
This medication was also not given on January 13, 18-19, 22-25, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
Client #2 was admitted on November 28, 2022 and discharged on May 3, 2023.
The client was prescribed a medication and the prescription stated that one tablet was to be taken twice daily. The medication administration records showed that the medication was not being given on December 2-4, 2022, January 6-9, February 6-7, 2023. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one tablet was to be taken at bedtime. The medication administration records showed that the medication was not being given on January 31, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
This medication was also not given on March 8, 2023. The documented reason for not being taken was " out of medication. "
Client #3 was admitted on December 13, 2022 and discharged on January 4, 2023.
The client was prescribed a medication and the prescription stated that one tablet was to be taken every twelve hours. The medication administration records showed that the medication was not being given on December 19, 2022. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that an injection was to be taken three times a day. The medication administration records showed that the medication was not being given on December 24-25, 2022. The documented reason for not being taken was " out of medication. "
This medication was also not given December 23, 26-28. 2022. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
The client was prescribed a medication and the prescription stated that one tablet was to be taken twice daily. The medication administration records showed that the medication was not being given on December 24-28, 2022. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
The medication administration records also show that the client had zero doses of the medication as of December 23, 2022 and the medication was not refilled until December 27, 2022.
The client was prescribed a medication and the prescription stated that one tablet was to be taken in the evening. The medication administration records showed that the medication was not being given on January 4, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
The client was prescribed a medication and the prescription stated that one tablet was to be taken twice daily. The medication administration records showed that the medication was not being given on January 3, 2023. The medication administration records showed that the client was at another location that date, but after the time the medication was to be taken. Other prescribed medications were documented to be given at the same time as this medication ' s dose. There was no additional documentation indicating a reason why the medication was not given as prescribed.
Client #4 was admitted on December 12, 2022 and discharged on March 25, 2023.
The client was prescribed a medication and the prescription stated that one tablet was to be taken twice daily. The medication administration records showed that the medication was not being given on December 15-27, 2022, January 10-12, 25, 27-31, 2023. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one capsule was to be taken nightly. The medication administration records showed that the medication was not being given on January 25, 2023. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one tablet was to be taken nightly. The medication administration records showed that the medication was not being given on January 25, 2023. The documented reason for not being taken was " out of medication. "
Client #5 was admitted on November 7, 2022 and still active at the time of the inspection.
The client was prescribed a medication and the prescription stated that one half of a tablet was to be taken at bedtime. The medication administration records showed that the medication was not being given on November 16-17, December 10-11, 2022. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one tablet was to be taken daily. The medication administration records showed that the medication was not being given on December 4-5, 2022, February 10, 2023. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that two tablets was to be taken daily. The medication administration records showed that the medication was not being given on December 2, 2022. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one tablet was to be taken daily. The medication administration records showed that the medication was not being given on February 8, 10, 2023. The documented reason for not being taken was " out of medication. "
Client #6 was admitted on February 15, 2023 and still active at the time of inspection.
The client was prescribed a medication and the prescription stated that two tablets was to be taken daily. The medication administration records showed that the medication was not being given on April 7, May 17, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
This medication was also not given on May 15-16, 2023. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one tablet was to be taken daily. The medication administration records showed that the medication was not being given on April 7, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
This medication was also not given on May 15, 2023. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that two tablets was to be taken daily. The medication administration records showed that the medication was not being given on April 7, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
This medication was also not given on May 16, 2023. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one tablet was to be taken twice daily. The medication administration records showed that the medication was not being given on April 7, May 10, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
This medication was also not given on May 5, 8-9, 2023. The documented reason for not being taken was " out of medication. "
The client was prescribed a medication and the prescription stated that one tablet was to be taken three times a day. The medication administration records showed that the medication was not being given on April 7-10, 13, 17, 21, 23-24, May 1-5, 7-14, 18-19, 21-24, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on these dates.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following our immediate internal investigation, a staff meeting was held on 6/2/2023, addressing medication policies and procedures and a deeper look at MAR documentation with a focus on when, where, what, and how to document.
Further internal investigation and collaboration led to procedural changes identifying workflow flaws prompting the utilization of a new electronic system (QuickMAR) to be implemented in early July 2023. The new system is designed to initiate and prompt for responses regarding each med pass for each resident for each med time which should eliminate documentation errors of omission. Along with the electronic MAR system, additional checks and balances will be implemented for a quality check at the beginning and end of each shift to review documentation and medication count status. The electronic system streamlines the prescription re-order process. All staff will be trained to use the new electronic QuickMAR by 06/30/23.
An alternate pharmacy has been engaged that can communicate with the electronic MAR, and the communication process with them is more transparent and the pharmacy will be taking on the follow-up actions with the prescribers so that refills are filled and shipped on time. This conversion to the new pharmacy has already begun and will continue as they phase in new scripts as they are due.
A new staff position will be created and posted for bid by mid-July. Once a selection has been made, this employee will be trained on our medication policies and procedures and also on our electronic QuickMAR. Their primary responsibility will be to pass meds, review med counts and medication inventories, document resident compliance or noncompliance with prescribed medications, document and track all correspondence with prescribing entities, and track, remind, and follow-up with resident health-care appointments ensuring they take with them a copy of their medication list and ensure they turn in any discharge paperwork when they return to the facility so that any adjustments can be updated in the electronic system. This employee will implement a follow-up protocol to initiate refill requests at least four days before the medication count reaches zero and verify receipt of delivered medications. Any situations that arise that would threaten the timely and successful refill or delivery of medications will be referred to the Clinical Director for follow-up, to include personal visits to prescribing authorities, phone calls or visits to pharmacies, and resident consultations. They will provide a daily summary report to their supervisor, including the Clinical Director and the Executive Director.
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Observations
Based on applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in three of five records.
Client #1 was admitted on October 28, 2022 and discharged on May 3, 2023. A treatment and rehabilitation plan was developed on January 11, 2023. A treatment and rehabilitation plan update was due no later than February 11, 2022, but was not completed until February 17, 2022.
Client #4 was admitted on December 12, 2022 and discharged on March 25, 2023. A treatment and rehabilitation plan was developed on December 30, 2022. A treatment and rehabilitation plan update was due no later than January 30, 2023, but was not completed until February 2, 2023.
Client #5 was admitted on November 7, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 30, 2023. A treatment and rehabilitation plan update was due no later than March 1, 2023, but was not completed until March 24, 2023.
A treatment and rehabilitation plan was developed on March 24, 2023. A treatment and rehabilitation plan update was due no later than April 24, 2023, but was not completed until April 26, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will address the standards for completing treatment plan updates in a staff meeting by 06/30/23. The Clinical Director or designee will ensure that all treatment plan updates will be reviewed during a weekly case management team meeting the week before they are due. The Clinical Director or designee will follow-up to ensure that updates are completed within the required time frames. |