Observations
Based on a review of the facility 's policy manual and medication storage area inspection logs, the facility failed to document monthly inspections of the medication storage areas as required by agency policy.
The findings include:
The monthly medication storage area inspection logs from April 2012 to August 2012 were reviewed on September 10, 2012. Per agency policy, inspections of the medication storage areas are to be conducted monthly. There were no medication storage area inspections for the following months: Dakota - missing August 2012, Seneca missing April 2012 and August 2012, Mountain Top missing August 2012, Mohican missing August 2012, Medical office missing May 2012 and August 2012, and no signatures on July 2012.
This was discussed with the Quality and Compliance Specialist on September 10, 2012 and the findings were not disputed.
This is a repeat citation from the February 7 - 9, 2011 and March 19-21, 2012 licensing inspections.
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Plan of Correction
The Nurse Manager changed the medication storage from the individual dorms and stored them in the Medical Office in August 2012. The LPN completed the Medication Storage Area Inspection and documented the Medication Storage Area Inspection Log for the Medical Office on August 22, 2012. The August Medication Storage Area Inspection Log was not filed in the Medication Storage Area Inspection Binder for the On-Site follow up visit conducted on September 10, 2012.
The Nurse Manager is responsible for conducting the Medication Storage Area Inspections and documenting the Medication Storage Area Inspection Log. The completed log is filed in the Medication Storage Area Binder located in the Medical Department. The Quality & Compliance Specialist reviews the completed Medication Storage Area Inspection Log and tracks that it is completed each month. The Nurse Manager provides a report of his inspection results at the Safety Committee meeting each month. The Nurse Manager completed the Medication Storage Area Inspection on September 27, 2012.
Effective November 1, 2012, the Medication Storage Area Inspection and the documented Medication Storage Area Inspection Log will be filed by the 20th of each month.
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