709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in three of nine client records.
Client #1 was admitted on March 28, 2024 and discharged on July 2, 2024. The client was prescribed a medication and the prescription stated that 50 mg was to be takeat bedtime daily. The medication administration records showed that the medication was not given from May 30 - June 4, 2024.
Client #1 was prescribed a medication and the prescription stated that 500mg x2 was to be taken every morning. The medication administration records showed that the medication was not given on June 1-12, 2024.
Client #5 was admitted on May 8, 2024 and discharged on July 7, 2024. The client was prescribed a medication and the prescription stated that 30 mg was to be taken daily at bedtime. The medication administation records showed that the medication was not given on June 22-26, 2024.
Client #10 was admitted on September 5, 2023 and discharged on July 31, 2024. The client was prescribed a medication and the prescription stated that 100 mg was to be taken daily at bedtime. The medication administation records showed that the medication was not given on May 21-22, 2024.
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Plan of Correction
The Acting Executive Director has taken the lead on medication management. A spreadsheet has been created to track the medication for all residents. Specifically, the following information: Rx number, Medication name, mg prescribed, dosage, number of refills remaining, Prescriber, the number of pills remaining, the last refill date, estimated date to run out, the next appointment with prescriber (if new script is needed) and notes to document when the refill should be called in.
The Clinical Director and the Acting Executive Director have delineated roles for medication management such as the Acting Executive Director will manage the spreadsheet, and the Clinical Director is responsible for ensuring all refills are requested timely. This should eliminate the incident of the medications not being on site when needed by the resident. The facility had already switched pharmacies as the previous pharmacy did not communicate well and the medication was often not delivered in time. The new pharmacy delivers daily even on Saturdays. The only staff authorized to remove medications from the QuickMAR system is the Clinical Director and the Acting Executive Director. The Program Assistant staff have also been informed via email the importance of good documentation being entered into the QuickMAR system. The documentation will be reviewed monthly and as improvement is made, then documentation will be reviewed quarterly. This will be completed by the Acting Executive Director and then feedback will be provided as needed to the appropriate staff. |