Observations
Based on a review of applicable client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in one of two records.
Client #2 was admitted on March 31, 2026 and was still active at the time of the inspection.
A medication was prescribed to be taken three times a day and documented on the medication form to be taken at 8:00am, 2:00pm, and 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 2:00pm on:
April 1, 2026, April 9, 2026, April 10, 2026, April 16, 2026, April 17, 2026, April 21, 2026, and April 24, 2026.
A medication was prescribed to be taken once daily and documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on:
April 4-29, 2026. The MAR states that the client was out of the medication; however, there was no documentation of the medication being discontinued or attempts to refill the prescription.
A medication was prescribed to be taken once daily at bedtime and documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on:
April 9, 2026, April 16, 2026, April 17, 2026, April 19, 2026, and April 28, 2026.
A medication was prescribed to be taken twice daily and documented on the medication form to be taken at 8:00am and 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00am on:
April 7, 2026, April 12, 2026, April 18, 2026, and April 27-30, 2026.
After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00pm on:
April 9, 2026, April 12, 2026, April 16, 2026, April 19, 2026, and April 27-28, 2026.
A medication was prescribed to be taken once daily and documented on the medication form to be taken at 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given on:
April 15, 2026, April 16, 2026, April 19, 2026, April 28, 2026, and April 29, 2026.
A medication was prescribed on April 25, 2026 to be taken as one half tablet once daily for seven day, then one tablet once daily for an additional seven days, then one and one half tablets daily for remainder of prescription. The medication was documented on the medication form to be taken at 8:00am. After a review of the facility medication administration records, there was no documentation of the medication being given on:
April 25, 2026.
A medication was prescribed on April 22, 2026 to be taken four times daily for seven days and documented on the medication form to be taken at 8:00am, 12:00pm, 4:00pm, and 8:00pm. After a review of the facility medication administration records, there was no documentation of the medication being given at 12:00pm on:
April 24, 2026.
After a review of the facility medication administration records, there was no documentation of the medication being given at 4:00pm on:
April 25, 2026 and April 29, 2026.
After a review of the facility medication administration records, there was no documentation of the medication being given at 8:00pm on:
April 26, 2026 and April 29, 2026.
This is a repeat citation from the January 21, 2026 annual licensing inspection.
This was finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Upon identification of this finding, the facility conducted a comprehensive review of medication administration records and medication management practices to identify gaps in documentation and oversight. While medications may have been administered as prescribed, documentation was not consistently completed in accordance with facility policy, and there was insufficient documentation regarding medication refill efforts and physician communication when medications became unavailable. To address this deficiency, the Family Healing Center implemented a revised medication administration and documentation process that requires staff to document medication administration immediately following administration and to document all medication refill requests, pharmacy communications, physician notifications, and medication availability issues. In addition, a Medication Refill Tracking Log has been implemented to monitor medication inventory and proactively address refill needs before medications are depleted. Supervisory staff will conduct weekly MAR audits and monthly quality assurance reviews to verify medication administration documentation, identify discrepancies, and provide corrective coaching as needed. Medication administration staff have been re-educated on documentation requirements, medication accountability standards, and procedures for addressing unavailable medications. Ongoing monitoring will continue through the facility's quality assurance program to ensure sustained compliance and prevent recurrence of this finding.
|