Observations
Based on six of six applicable client records reviewed, the facility failed to provide documentation of the administration of medication according to the facility policy and procedure manual. The policy and procedure manual indicates that both the staff and client will document on the medicated administration record whether or not the medication was taken.
Client # 1 was admitted on December 20, 2021 and was still active at the time of the inspection. A medication prescribed to be taken two times by spray was not documented on the medication administration record to have been taken two times by spray on the dates of December 21-25, 28-31, 2021, January 2, 6-9, 10-19, 21-23, 25, 26, and February 1-4 and 6-8, 2022. A medication prescribed to be taken one capsule four times a day was not documented on the medication administration record to have been taken four times a day on the dates of December 24-30, 2021, January 11, 21-24, 27-29, and February 2, 3, and 6, 2022.
Client # 2 was admitted on January 3, 2022 and was still active at the time of the inspection. Two medications prescribed to be taken one tablet daily at 9pm was not documented on the medication administration record to have been taken one tablet daily at 9pm on the dates of January 12, February 1, 3, 8 and January 11, 12, 14, 26, and February 1-8, 2022. Also, a medication prescribed to be taken one time daily was not documented on the medication administration record to have been taken one time daily on the dates of January 6 and 12, 2022. A medication prescribed to be taken three tablets daily at 7am was not documented on the medication administration record to have been taken three tablets daily at 7am on the dates of January 5, 6, 10, 19, 21, 25, and February 8, 2022. A medication prescribed to be taken one tablet daily at 7am was not documented on the medication administration record to have been taken one tablet daily at 7am on the dates of January 6, 8, 22, 23, 2022. A medication prescribed to be taken one capsule daily at 7am was not documented on the medication administration record to have been taken one capsule daily at 7am on the dates of January 8, 14, 22, 23, 2022.
Client # 4 was admitted on January 4, 2022 and was still active at the time of the inspection. A medication prescribed to be taken one time daily at 7 am was not documented on the medication administration record to have been taken one time daily at 7 am on the date of January 5-21, 23, and February 9, 2022.
Client # 5 was admitted on May 17, 2021 and was discharged on June 18, 2021. A medication prescribed to be taken one tablet two times a day at 7am and 4pm was not documented on the medication administration record to have been taken one tablet two times a day at 7am and 4pm on the dates of May 18, 30, and June 4, 16, 2021.
Client # 6 was admitted on July 27, 2021 and was discharged on November 12, 2021. Two medications prescribed to be taken one capsule daily at 9pm was not documented on the medication administration record to have been taken one capsule daily at 9pm on the dates of July 28, 29, September 21, 26, 28, October 23, 31, November 4, 2021 and August 6, 19, September 21, 26, 28, October 23, 31, and November 9, 2021. Two medications prescribed to be taken three times daily at 7am, 4pm, and 9pm and 7am, 11am, and 4pm was not documented on the medication administration record to have been taken three times daily at 7am, 4pm, and 9pm and 7am, 11am, and 4pm on the date of July 29, 31, August 8, 9, 11, 17, 18, 19, 22, 26, 28, 29, September 4, 6, 13, 18, 21, 24, 25, 28, October 2, 3, 6, 14, 20, 21, 22, 23, 27, 28, 31, November 4, 10, 2021 and July 29, 30, August 1, 4, 8-11, 13, 16-31, September 4, 6, 11,13, 26, October 2, 3, 6, 11, 14, 17, 20, 22, 23, 27, 28, 29, 31, and November 6, 8-11. 2021. Another medication prescribed to be taken one tablet daily at 7 am was not documented on the medication administration record to have been taken one tablet daily at 7 am on the date of August 22, 28, 29, September 13, 25, 26, and October 3, 5, 31, 2021. A medication prescribed to be taken one tablet daily at 9 pm was not documented on the medication administration record to have been taken one tablet daily at 9 pm on the dates of August 19, 29, September 21, 28, October 16, 23, 31, and November 2, 4, 2021.
Client # 7 was admitted on November 12, 2021 and was discharged on December 29, 2021. Three medications prescribed to be taken one tablet two times daily at 7am and 4pm was not documented on the medication administration record to have been taken one tablet two times daily at 7am on the dates of December 26, December 26, and November 25, December 12, 6, 18, 26, 28, 2021. A medication prescribed to be taken one tablet daily at 7am was not documented on the medication administration record to have been taken one tablet daily at 7am on December 24, 2021. A medication prescribed to be taken one tablet daily at 9pm was not documented on the medication administration record to have been taken one tablet daily at 9pm on November 13, 15-24, 26-30, December 1-17, and 19, 2021. A medication prescribed to be taken one capsule daily at 9pm was not documented on the medication administration record to have been taken one capsule daily at 9pm on November 15, 23, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.32 (c), the following will be implemented:
Beginning on 3/3/2022, the Clinical Director will ensure that all staff are trained on documenting whether or not the client has taken their medication on the Medication Administration Records. The staff assigned to complete the observation of the administration of medications, will indicate the reason why the client did not take their medication on the Medication Administration Records, and have the client sign off.
The Director of Programs will monitor the progress of this action plan during monthly supervisions.
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