709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered as prescribed in two of six records reviewed.
Client #4 was admitted April 10, 2024 and discharged June 28, 2024. A medication was prescribed to be given once a day. The MAR was left blank every day between May 27, 2024 and June 27, 2024.
Client #7 was admitted May 3, 2024 and still a current client. A medication was prescribed to be given four times a day. The MAR was left blank every time it should have been administered for every day between June 26, 2024 and July 20, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Program Director informed all program staff of licensing review results and reminded staff of the requirement to document the appropriate information for every medication administration time (passed, missed, refused, not arrived, etc.). 8/8/24
2. Additional training for program staff was provided by the Nurse Manager at Crossroads and EHR Analyst to reinforce documentation requirements. 8/9/24
3. Program Director will run the "eMAR Missing Administration Events Report" weekly to identify missing documentation and provide a copy of the report to staff to follow up with deficiencies. Staff will have 48 hours to correct documentation, barring any IT issues that would prevent it. Ongoing |