Observations
Based on a review of the facility's medication administration records and an interview with the facility director, the facility failed to document medication records in accordance with facility policy.
Findings:
Facility policy titled "Nuestra Clinica Residential Medication Policies Section 709.32c" Page 4 states: "In the event that a client refuses a prescribed medication, staff will document the client's refusal in the Medication Administration Log and contact the on call medical staff to review the situation if the client's refusal could be considered an immediate health risk."
Facility policy titled "Nuestra Clinica Residential Medication Policies Section 709.32c" Page 7 states: "When a client discontinues taking a particular type of prescribed medication, the disposal of that medication will be documented on his medication log if appropriate, by the staff member who disposed of medication."
The facility failed to follow their policy and document whether or not a client received their medication, whether a client refused their medication, whether the medication was discontinued, or whether the medication was being taken as prescribed, in five medication records reviewed.
Client # 1
Drug: Vistaril 25 MG - Frequency: take 1 to 2 caps at bedtime
Dates not taken: 6/9/2011, 6/10/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: Who entered the information (staff signature), the prescription date, the prescribing doctor, the client's dated signature indicating their agreement to take the medication, and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Client #2
Drug: Risperdal 1 mg, Prescribed on 5/20/11, Frequency: Take 1.5 tablets every AM. Dates not taken: 5/22/11, 5/23/11, 5/25/11, 5/26/11, 6/2/11, 6/3/11 and 6/13/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication, and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Drug: Trazodone 100 mg: Frequency: 1 tablet at bedtime. Date not taken: 5/26/11, 5/27/11, 5/28/11, 5/29/11, 5/31/11, 6/4/11, 6/5/11, 6/6/11, 6/7/11, 6/8/11, 6/9/11, 6/10/11, 6/11/11 and 6/12/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication, and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Drug: Cogentin 0.5 mg. Frequency: Take twice a day (form states morning and evening dose time). The medication administration record only shows that the client was taking one dose in the evening from May 20, 2011 through June 12, 2011.
Facility staff reported that the client was taking a double dose in the evening. This was not documented on the medication administration record. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication, and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Client #4
Drug: Chlorpromazine 100 mg. Prescribed on 5/20/11. Frequency: 1 tablet at bedtime. Dates not taken: 5/22/11, 5/29/11, 6/3/11, 6/5/11 and 6/6/11.
There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Client #9
Drug: Valtrex 500 MG. Prescribed on 5/26/11. Frequency: 1 tablet everyday.
Dates not taken: 5/28/11, 5/29/11, 5/30/11 5/31/11 and 6/1/11. There was no documentation as to why the client skipped or missed a dosage.
Client #10
Drug: Benztropine 0.5 mg. Prescribed on 1/13/11. Frequency: 1 tablet at bedtime.
Dates not taken: 5/12/11, 5/18/11, 5/21/11 and 6/09/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for following dates: 5/3/11, 5/4/11, 5/5/11, 5/10/11, 5/11/11, 5/14/11, 5/16/11, 5/17/11, 5/19/11, 5/20/11, 5/25/11, 5/30/11, 6/1/11, 6/2/11, 6/10/11 and 6/11/11. There was no documentation of the prescribing physician.
Drug: Risperidone 2 mg. Prescribed on 5/2/11. Frequency: 1 tablet by mouth at bedtime. Dates not taken: 5/12/11, 5/18/11 and 6/9/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for following dates: 5/3/11, 5/4/11, 5/5/11, 5/10/11, 5/11/11, 5/14/11, 5/15/11, 5/16/11, 5/17/11, 5/19/11, 5/20/11, 5/23/11, 5/25/11, 5/30/11, 6/1/11, 6/2/11, 6/6/11, 6/10/11 and 6/11/11. There was no documentation of the date of the prescription.
Drug: Klor-Conmzo. Prescribed on 5/3/11. Frequency: 1 tablet daily. Dates not taken: 5/30/11, 5/31/11, 6/9/11 and 6/10/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/5/11, 5/9/11, 5/16/11, 5/18/11, 5/23/11, 5/24/11, 5/28/11, 6/6/11 and 6/8/11.
Drug: Furosemide 40 mg. Prescribed on 5/3/11. Frequency: 1 tablet daily. Dates not taken: 5/11/11, 5/30/11, 5/31/11, 6/9/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/5/11, 5/9/11, 5/16/11, 5/18/11, 5/23/11, 5/24/11, 5/28/11, 6/6/11 and 6/8/11
Drug: Omeprazole 20 mg. Prescribed on 5/5/11. Frequency: 1 capsule daily. Dates not taken: 5/3/11, 5/30/11, 5/31/11, 6/9/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/4/11, 5/9/11, 5/16/11, 5/18/11, 5/23/11, 5/24/11, 5/28/11, 6/6/11 and 6/8/11. There was no time documented for the dosage given on 6/17/11. There was no documentation of the prescribing physician.
Drug: Folic Acid 1 mg. Prescribed on 5/3/11. Frequency: 1 tablet in the morning.
Dates not taken: 5/3/11, 5/30/11, 5/31/11, 6/10/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/5/11, 5/9/11, 5/16/11, 5/18/11, 5/23/11, 5/24/11, 6/6/11, 6/7/11 and 6/8/11. There was no documentation of the prescribing physician.
Drug: Thiamine 100 mg. Prescribed on 5/2/11. Frequency: 1 tablet daily. Dates not taken: 5/3/11, 5/30/11, 5/31/11, 6/9/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/2/11, 5/5/11, 5/9/11, 5/16/11, 5/18/11, 5/23/11, 5/24/11, 6/6/11 and 6/8/11. There was no documentation of the prescribing physician.
Drug: ASA 325 mg. Prescribed on 5/2/11. Frequency: 1 tablet daily. Dates not taken: 5/3/11, 5/30/11, 5/31/11, 6/9/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/2/11, 5/5/11, 5/9/11, 5/14/11, 5/16/11, 5/18/11, 5/23/11, 5/24/11, 6/6/11, 6/8/11 and 6/10/11. There was no documentation of the prescribing physician.
Drug: MVI. Prescribed on 5/2/11. Frequency: 1 tablet daily by mouth. Dates not taken: 5/3/11, 5/30/11, 5/31/11, 6/9/11, 6/11/11 and 6/12/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/2/11, 5/9/11, 5/16/11, 5/18/11, 5/23/11, 5/24/11, 6/6/11 and 6/8/11. There was no documentation of the prescribing physician.
Drug: Citalopram 20 mg. Prescribed on 5/2/11. Frequency: 1 tablet daily by mouth.
Dates not taken: 5/3/11, 5/30/11, 5/31/11, 6/8/11, 6/9/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/2/11, 5/5/11, 5/10/11, 5/16/11, 5/18/11, 5/23/11, 5/24/11 and 6/6/11. There was no documentation of the prescribing physician.
Drug: Glucotrol 5 mg. Prescribed on 5/5/11. Frequency: 2 tablet daily with food
Date not taken: 5/9/11, 5/23/11, 5/24/11, 5/25/11, 5/26/11, 5/27/11, 5/30/11, 5/31/11, 6/1/11, 6/9/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/16/11, 5/18/11, 5/28/11, 6/6/11 and 6/8/11. The time of day the dosages were given on 5/5/11 and 5/6/11 were missing.
Drug: Gabapentin 300 mg. Prescribed on 5/5/11. Frequency: 1 tablet by mouth 2x daily. Dates not taken: 5/27/11, 5/30/11, 5/31/11, 6/2/11, 6/3/11 and 6/11/11.
There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 5/24/11, 5/25/11, 5/26/11, 5/30/11, 6/1/11, 6/6/11, 6/8/11, 6/10/11 and 6/11/11. There was no documentation of the time the client took the dose on 6/9/11. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Drug: Warfarin 7.5 mg. Frequency: 1 tablet daily along with 2 mg tablet. Dates not taken: 6/9/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 6/6/11, 6/8/11 and 6/10/11. The medication administration record was missing the following information: the prescription date, the prescribing physician, the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Drug: Warfarin sodium 2 mg. Prescribed on 5/26/11. Frequency: 1 tablet daily with 7.5 mg. Dates not taken: 5/30/11, 5/31/11, 6/9/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 6/6/11 and 6/8/11. The medication administration record was missing the following information: staff signature and date who entered the information, the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Drug: Metformin 850 mg. Frequency: 1 tablet twice daily then ???
Dates not taken: 5/30/11 (only once), 5/31/11 (only once), 6/11/11 (only once) and 6/9/11 (not at all). There was no documentation as to why the client skipped or missed a dosage. The client sign off was missing for the following dates: 6/2/11, 6/8/11, 6/10/11 and 6/11/11. The medication administration record was missing the following information: staff signature and date who entered the information, the prescription date, the prescribing physician, the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Client #11
Drug: Effexor xr 75 mg. Prescribed on 5/30/11. Frequency: Take 1 capsule daily in the AM. Dates not taken: 6/4/11, 6/6/11 and 6/12/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given. The clients ID number was not documented on the medication form.
Client #12
Drug: Vistaril. Prescribed on 6/6/11. Frequency: Take one or two tab at bedtime
Dates not taken: 6/6/11, 6/10/11, 6/11/11, 6/12/11, 6/13/11 and 6/14/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Drug: Zoloft 50 mg. Prescribed on 5/26/11. Frequency: Take one everyday.
Dates not taken: 5/29/11, 5/31/11, 6/1/11, 6/2/11, 6/3/11, 6/4/11, 6/5/11, 6/6/11, 6/9/11, 6/10/11, 6/11,11, 6/13/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication.
Client #13
Drug: Zyprexa 15 mg. Frequency: Take one daily a bedtime. Dates not taken: 6/4/11, 6/8/11 and 6/12/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: staff signature and date who entered the information, the prescribing physician and the prescription date, the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Staff did not sign the 6/2/11 dosing entry.
Drug: Trazodone 100 mg. Prescribed on 6/8/11. Frequency: Take one tab at bedtime. Dates not taken: 6/8/11 and 6/12/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication.
Drug: Ketoconazole. Frequency: Take one daily. Dates not taken: 6/4/11 and 6/8/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: staff signature and date who entered the information, the prescribing physician and the prescription date, the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Client #14
Drug: Trazodone 100 mg. Prescribed on 4/21/11. Frequency: Take two at bedtime.
Dates not taken: 5/2/11, 5/3/11, 5/5/11, 5/6/11, 5/7/11, 5/9/11, 5/10/11, 5/19/11, 5/20/11, 5/22/11, 6/1/11, 6/3/11 and 6/12/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Client #15
Drug: Naproxen 500 mg. Prescribed on 5/3/11. Frequency: Take one tab twice daily. Dates not taken: 5/8/11 (one time), 5/9/11 (one time), 5/10/11 (not at all), 5/14/11 (one time), 5/15/11 (not at all), 5/16/11 (not at all), 5/21/11 (one time), 5/22/11 (one time), 5/23/11 (one time), 5/26/11 (one time), 5/27/11 (one time), 5/28/11 (not at all), 5/29/11 (not at all), 6/1/11 (one time), 6/2/11 (one time), 6/3/11 (one time), 6/6/11 (one time), 6/7/11 (not at all), 6/8/11 (not at all), 6/9/11 (not at all) 6/10/11 (not at all), 6/11/11 (not at all) and 6/12/11 (not at all). There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given. There was no documentation of the prescribing physician.
Drug: Simuastin 40 mg. Frequency: Take one at bedtime. Dates not taken: 6/10/11. There was no documentation as to why the client skipped or missed a dosage.
The medication administration record was missing the following information: staff signature and date who entered the information, the prescribing physician and the prescription date, the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Drug: Metformin HCL 1,000 mg. Prescribed on 5/22/11. Frequency: Take one twice daily. Dates not taken: 6/1/11 (one time), 6/6/11 (one time), 6/13/11 (morning dose not taken). There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Client #16
Drug: Seroquel 100 mg. Prescribed on 6/10/11. Frequency: Take one at bedtime
Dates not taken: 6/11/11 and 6/12/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Client #17
Drug: Citalopram (celexa) 40 mg. Prescribed on 5/28/11. Frequency: One tab every morning. Dates not taken: 5/29/11, 5/30/11, 5/31/11, 6/2/11, 6/3/11, 6/4/11, 6/5/11, 6/7/11, 6/8/11, 6/10/11, 6/11/11, 6/12/11 and 6/13/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Drug: Risperidone 2 mg. Prescribed on 5/28/11. Frequency: Take one at bedtime
Dates not taken: 5/29/11, 5/30/11, 5/31/11, 6/2/11, 6/3/11, 6/4/11, 6/5/11, 6/6/11, 6/7/11, 6/9/11, 6/10/11 and 6/11/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
Drug: Lisinopril 10 mg. Prescribed on 5/28/11. Frequency: Take one once a day
Dates not taken: 5/29/11, 5/30/11, 5/31/11, 6/2/11, 6/3/11, 6/4/11, 6/5/11, 6/7/11, 6/8/11, 6/10/11, 6/11/11, 6/12/11 and 6/13/11. There was no documentation as to why the client skipped or missed a dosage. The medication administration record was missing the following information: the client's dated signature indicating their agreement to take the medication and the staff signature indicating the potential side effects were explained to the client and the date the explanation was given.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the January 24, 2011 through January 25, 2011 licensing inspection. The facility's plan of correction submitted on March 10, 2011 and approved on March 22, 2011 stated the following:
" On February 16, 2011 a staff meeting was held and all staff were educated on the medication policy and asked to sign a form acknowledging attendance at the training. Staff were informed that in the event of a client refusing medication, the staff person must document the refusal in the medication book, date the book, and initial the medication log as to whether client failed to come in the office for mediation or that the client refused the medication. The on duty staff will then call the nurse and advise of the refusal. If the situation is not life threatening, the nurse,upon her return to the facility, will educate the client on the risks involved in medication non compliance. In addition, the nurse will advise the client's primary counselor of the non compliance issue and the counselor will add this problem to the treatment plan and future goals for the client. If the client remains non compliant they will be referred for a mental health assessment by psychiatrist. If the evaluation concludes the client should remain on medication then the client must adhere or face progressive disciplinary actions including loss of privileges up to possible discharge. If medication is discontinued by physician/psychiatrist it will be documented on the medication log, medication will be properly disposed of, and documentation of when and who disposed of the medication will be kept. Staff will also be held accountable for the documentation of medication and refusals. This will be overseen by the nurse,associate director and the project director. Failure to comply will result in disciplinary measures stated in the employee handbook, which includes possible termination. ***** The nurse will review the medication sheets daily for compliance. Any discrepancies will be reported to the associate director and the employee will be retrained by the nurse. If any employee has further problems with documentation after the initial training they will be placed on a probationary period to allow direct supervision of procedure. Failure to comply with policy during the probation period may result in disciplinary action up to and including termination**. "
An interview with the facility director on June 13, 2011 confirmed the findings.
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Plan of Correction
A staff meeting was held on June 21, 2011. At this time several employees received warnings which were placed in their personnell file. THe nurse was also given a verbal warning for non compliance with daily monitoring of the medication book. The nurse agrees to review the medication sheets daily for compliance. Any discrepancies will be reported to the associate director, the director and the employee. If any employee has further problems with documentation additional training will be provided and disciplinary measures will escalate. Employee will not be allowed to observe self medication alone until satisfactory standards have been met. Retrainining has been scheduled for the entire staff to ensure understanding of self medication procedures. In addition any client that refuses or does not come at medication time will receive behavioral contract that if not followed could casue client to be transferred or discharged for non compliance of facility rules. We will also refer client back to psychiatrist for re-evaluation of medication and possible d/c or change in medications. |