INITIAL COMMENTS
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This report identifies the findings of an on-site complaint investigation conducted on June 14, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on August 16, 2006.
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Plan of Correction
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709.26(b)(3) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(3) The orientation of new employes.
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Observations
There were no written policies and procedures on the orientation of nurses. The personnel records of eight nurses were reviewed and revealed that there was no documentation of orientation provided specific to nurses.
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Plan of Correction
The policy identified as: NURSING ORIENTATION is being faxed to the DAPL office this morning. This policy was located and available in the Nursing Manual on the date of the site visit. I am unclear as to how it did not get presented to the auditors. Feedback welcome on the quality of the policy.
As an example: Orientation for staff member Nurse # 1 is being faxed to the DAPL office this morning as well. Please note that the "Job Description" serves many purposes over a staff member's employment.
- Job Description
- Supervision document
- 90 day evaluation
- Orientation
- Self-Evalutation
- Annual Evaluation
- Skills Checklist
- Other
At an employee's 90 day evaluation, the duties are reviewed to assure that a proper orientation has been done. Since we have a separate check box line item for 90 day eval and for orientation, only 90 day eval was being checked. This appears to be the case for all staff charts audited.
POC: The "Job Descriptions" have been changed to indicate 90 day eval/Orientation effective 8/7/06.
Per a verbal discussion with the auditors and co-DON acting: with regards to a Orientation time line. A newly developed Nursing Orientation Outline is being faxed to the DAPL office this morning - put into effect 8/20/06.
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Employee #2 is currently not allowed to practice in the capacity of a licensed nurse as directed by the Department of State. This directive has limited employee #2's duties and this nurse is now working as a nursing assistant. The job description for employee #2 was for a licensed nurse, not a nursing assistant.
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Plan of Correction
Job description signed by employee # 1 as a Nursing Assistant 8/2/06. This will be faxed to the DAPL office this morning. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
1. A blue bottle filled with dicyclomine tablets was in the desk drawer located near the dutch doors of the dispensing area. The bottle was not the original bottle that the drug came in and had no patient name for which it was prescribed, instructions, date received, number of units, lot number, expiration date, or any information other than the drug name and the number of milligrams. When asked about the bottle of dicyclomine, employee #1 stated that when a patient leaves treatment their remaining medications are not destroyed, but rather put into a "common bottle" for other patients who may need them.
2. Based on staff interviews and the documentation for wasted medications, it was determined that nurses are pre-pouring medications. This is not consistent with the facility's policies and procedures which state "at the scheduled medication time when patient comes to Nursing Office, the nurse shall pour medications directly from the MAR and administer to the patient" and "in compliance with pharmacy regulations, no medications are to be pre-poured or charted before administered".
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Plan of Correction
1. All medications that were not directly associated with a patient with proper documentation have been destroyed. The unit has been inspected by co-DON's Acting and this Executive Director.
The Nursing Unit is in the process of changing over to Unit Dosing vs. Bubble Packs. The Pharmacy has agreed to take back all "left behind" medications in the bubble packs and destroy for us until we are completely changed to the Unit Dosing. At that time, all "left behind" Unit Doses will be returned to the pharmacy.
The Unit Dose process will be fully implemented by September 29, 2006.
2. The practice of pre-pouring meds is not an acceptable practice and all nurses have been re-educated as such as of 8/9/06 during mandatory meeting held by co-DON's acting and this Executive Director.
The Nurses shifts are being changed as of 9/9/06 to be more consistent with medication administration times. When the unit changes to Unit Dosing, the doses will be pre-pulled since each dose has name and expiration of med on each dose.
Policy will be changed to reflect such when Unit Dosing is completely implemented. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
There was a box of sample drugs that were not in the locked cabinet in the doctor's office. Instead, they were sitting on the floor.
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Plan of Correction
All sample medications that are not assigned to a patient are now locked in the designated cabinet in the doctor's office.
Unit Inspected by co-DON, acting and this Executive Director.
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709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
1. A blue bottle filled with dicyclomine tablets was in the desk drawer located near the dutch doors of the dispensing area. The bottle was not the original bottle that the drug came in and had no patient name for which it was prescribed, instructions, date received, number of units, lot number, expiration date, or any information other than the drug name and the number of milligrams. When asked about the bottle of dicyclomine, employee #1 stated that when a patient leaves treatment their remaining medications are not destroyed, but rather put into a "common bottle" for other patients who may need them.
2. Based on staff interviews and the documentation for wasted medications, it was determined that nurses are pre-pouring medications. This is not consistent with the facility's policies and procedures which state "At the scheduled medication time when patient comes to Nursing Office, the nurse shall pour medications directly from the MAR and administer to the patient" and "in compliance with pharmacy regulations, no medications are to be pre-poured or charted before administered".
3. Review of the facility's documentation for the wasting of medications noted that on 12/29/2005, five and one half tablets of Suboxone were wasted. Suboxone, per Reckitt-Benckiser the pharmaceutical manufacturer, is not to be cut in half as the tablets are not equally compounded.
4. The medication administration records did not correlate with the amount of medication remaining in blister packs on four out of six client records reviewed.
5. The medication administration record did not include the initials of the person administering the medication or list the reason why a patient did not receive a medication.
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Plan of Correction
1. All medications that were not directly associated with a patient with proper documentation have been destroyed. The unit has been inspected by co-DON Acting and this Executive Director.
The Nursing Unit is in the process of changing over to Unit Dosing vs. Bubble Packs. The Pharmacy has agreed to take back all "left behind" medications in the bubble packs and destroy for us until we are completely changed to the Unit Dosing. At that time, all "left behind" Unit Doses will be returned to the pharmacy.
The Unit Dose process will be fully implemented by September 29, 2006.
2. The practice of pre-pouring meds is not an acceptable practice and all nurses have been re-educated as such as of 8/9/06 during mandatory meeting held by co-DON's acting and this Executive Director.
The Nurses shifts are being changed as of 9/9/06 to be more consistent with medication administration times. When the unit changes to Unit Dosing, the doses will be pre-pulled since each dose has name and expiration of med on each dose.
Policy will be changed to reflect such when Unit Dosing is completely implemented
3. Per Reckitt-Benckiser guidelines, this practice was ended in the beginning of 2006. Re-educated all Nursing staff as of 8/9/06 during mandatory meeting held by co-DON's and this Executive Director.
4. Mandatory meeting held on 8/9/06 by co-DON's, Acting and this Executive Director to re-educate all Nursing Staff on proper and expected protocols and practices.
The Emergency Box for after hours medication needs has been re-evaluated. Minimal emergency medications are kept on hand and utilization is monitored by the pharmacy and medications are accounted for.
Effective, 7/7/06, protocols were revised to ensure that, at least, the first 5 days of medication is delivered within 24 hours of admit.
We will utilize Pharmacy to audit compliance.
5. Addressed during mandatory meeting held on 8/9/06 by co-DON's, Acting and this Executive Director. This will be an ongoing training and supervision issue monitored through Quality Improvement Process.
Documentation of medication administration occurs at the point of care. The nurse administering any prescribed medication will immediately document medication administration. Additionally, when patients do not receive prescribed medication, the MAR will reflect the missed dose and notation of the reason will be made on the MAR.
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709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
1. The facility's policy on Medication Specifications section "E" stipulated that Sample Drugs shall not be used, however, they also had a policy and procedure titled "Sample Medications" and the facility was using samples.
2. As part of the facility's policy and procedure titled "Sample Medications", a log was to be maintained with the following information:
a.Name.
b.Dose.
c.Date received.
d.Number of units.
e.Lot number.
f.Expiration date.
g.Medical record number of patient receiving medication.
h.Date signed out to patient or wasted due to expiration date.
i.Signature of two staff members signing out medication.
The sample log did not consistently define the date received or dispensed, nor did the log consistently list the medical record number of the client, or have two staff members sign the log for signing out medications.
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Plan of Correction
1. Deleted verbiage indicating that "Sample Drugs shall not be used" from "Medication Specifications policy section "E" Done: 8/7/06.
2. We have identified a staff team leader to oversee the Sample Medication Process. To allow enough time to accurately restart this process, target date is 8/25/06. This process will be monitored and overseen by the co-DON's acting and eventually permanent DON. It will also be part of the permanent pharmacy compliance audit.
a. All current samples on site will be properly classified and logged by a multi-disciplinary team (nursing, PA and pharmacy) according to the Sample Medication Log.
b. Log will be properly utilized to include
Name.
b.Dose.
c.Date received.
d.Number of units.
e.Lot number.
f.Expiration date.
g.Medical record number of patient receiving medication.
h.Date signed out to patient or wasted due to expiration date.
i.Signature of two staff members signing out medication.
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