Deficiency #1
Rule/Regulation Violated:
R9-10-816.B.3.c. Medication Services<br> B. If an assisted living facility provides medication administration, a manager shall ensure that: <br> 3. A medication administered to a resident: <br> c. Is documented in the resident's medical record.
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for five of five sampled residents.</p><p><br></p><p>Findings include:</p><p><br></p><ol><li>A review of controlled substance logs for R1, R2, R3, R4, and R5 revealed multiple single doses of opioid medications had been signed out from each resident's supply. However, the medication administration records (MARs) for each resident at the time those opioids were signed out did not include documentation of administration of those medications.</li><li>In an interview, E1 acknowledged the provided documentation of medications administered to each resident did not match the documentation of opioids removed from the medication cart. </li></ol>
Temporary Solution:
ED and WD completed an audit of the entire community's Narcotic logs to ensure no other errors in documentation were found. The noted errors in the inspection were addressed by the individuals involved in the error. All employees involved were removed from their roles as med techs.
Permanent Solution:
ED and WD will complete a hands-on training checklist with the remaining Med techs, including reviewing our policy and procedure on Narcotic Logs. Wellness Director will review the Narcotic Logs several times weekly to ensure that the documentation for each narcotic is complete and correct. ED will audit the Narcotic log and documentation with monthly EMAR audits to ensure errors do not recur.
Person Responsible:
Amy Ferguson Executive Director, And Tina Durante, LPN wellness Director
Summary:
No deficiencies were found during the on-site investigation of complaints 00145900, 00128190, and 00128189 conducted on October 8, 2025.