Inspection Findings:
Resident 3 was admitted to the facility in 2021 with diagnoses including diabetes. The resident's 03/01/22 through 03/28/22 MARs and physicians orders dated 03/22/22 were reviewed and revealed the following:* There were blanks 03/01/22 through 03/06/22 for the 7:00 am CBG data with no explanation of what the reading was; and* The was no documentation noting the amount of insulin given for the 7:00 am, 11:00 am or 4:00 pm doses of Novolog Flexpen insulin 03/04/22 through 03/27/22; and* There were blanks on 17 occasions between 03/04/22 and 03/28/22 for CBG data with no explanation of what the reading was. The need to ensure MARS were accurate and included the initials of the person administering the medication or tracking the required information was discussed with Staff 1 (Director) and Staff 2 (RN) and Staff 3 (Residential Care Coordinator) 03/04/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate and provided clear instruction and parameters for administration of PRN medications for 2 of 4 sampled residents (#s 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:Resident 5 was admitted to the facility in 1/2020 with diagnoses including pruritus (itching) of the skin. The resident's physician orders and 03/01/22 through 03/28/22 MARs were reviewed, and the following was identified: The resident had three PRN topical medications, hydrocortisone (anti-itch) cream, ketoconazole (antifungal) cream, and nystatin (antifungal) powder.Resident 5's 03/01/22 through 03/28/22 MAR lacked documented evidence the PRN creams and powder were being administered; however, interviews with the staff revealed these PRN creams and powder were being applied to the resident daily, but staff were not documenting the treatments on the MAR or anywhere else. The need to ensure staff signed their initials when treatment was administered on the MAR was discussed with Staff 3 (Residential Care Coordinator) on 03/30/22. She acknowledged the findings.
3. Resident 6 was admitted to the facility in 08/2022 with diagnoses including COPD. Review of the resident's current signed physician orders and the 08/01/22 through 08/22/22 MAR revealed the following: * Physician orders for PRN pain medications, including oral acetaminophen, acetaminophen suppository, morphine sulfate and oxycodone, were listed on the MAR. There were no parameters identified which instructed staff the sequence in which to administer the medications.* The MAR indicated scheduled topical fentanyl patches (for pain) were placed on the resident's skin on 08/14/22, 08/17/22, and 08/20/22, but did not identify the site of placement. * The resident had a PRN order for Naloxone Nasal Spray (opiod overdose treatment). There were no instructions to staff which identified the signs and symptoms of an overdose. * Instructions on the MAR for the administration of diltiazem (A-fib) included holding the medication if the resident's blood pressure was outside the listed parameters. On 08/13/22, 08/14/22, and 08/15/22, the medication was noted to have been administered, but there were blanks where staff were to have recorded the resident's blood pressure. The need to ensure the MAR was accurate and included clear instruction to staff was discussed with Staff 12 (ED/Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 11 (Regional Operations Director) on 08/23/22. They acknowledged the findings. 4. Resident 8 was admitted to the facility in 07/2021 with diagnoses including insulin-dependent diabetes. Current physician orders instructed staff to administer insulin based on a sliding scale which corresponded to the resident's blood glucose levels. Review of 08/01/22 through 08/22/22 MAR revealed staff were to document the site of administration, the number of insulin units needed and the number of insulin units given. The site of administration and the number of insulin units given were left blank on 08/05/22 and 08/18/22 for the 7 am medication pass.The need to ensure the MAR was accurate and included clear instruction to staff was discussed with Staff 12 (ED/Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 11 (Regional Operations Director) on 08/23/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 4 of 4 sampled residents (#s 6, 7, 8, and 9). This is a repeat citation. Findings include, but are not limited to:1. Resident 7 was admitted to the facility in 03/2021 with diagnoses including glaucoma and chronic constipation. A review of the resident's 08/01/22 through 08/22/22 MAR and current physician orders identified the following:* The resident was prescribed polyethylene glycol for constipation, along with three additional bowel medications. There were no parameters for when staff should administer the polyethylene glycol;* The resident had a physician's order for Imprimis (eye drops for glaucoma), but this was not on the MAR; and* An order for cyanocobalamin injections (Vitamin B-12) indicated it should be injected every 30 days starting 03/20/21. The MAR indicated a prescription for Vitamin B-12 was written on 04/13/22. Review of the current MAR (08/01/22 through 08/22/22) revealed the medication had not been administered.In interviews with Staff 2 (RN) on 08/23/22, she verified there were no parameters for the polyethylene glycol. She indicated she had a note on her desk the Vitamin B-12 injection had been administered on 08/15/22, but it had not been entered on the MAR. She stated the next injection was scheduled for 09/14/22. On the same date, Staff 3 (RCC) reported she had added the eye drops to Resident 7's MAR on 08/22/22.The need for the MAR to be accurate was discussed with Staff 12 (ED/Administrator) and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.2. Resident 9 was admitted to the facility in 01/2022 with diagnoses including anxiety. A review of the resident's 08/01/22 through 08/22/22 MAR revealed the following:* There were no parameters for docusate sodium 100 mg capsule (for constipation). The resident was prescribed two additional medications for constipation, and there was no direction to staff regarding when to administer docusate sodium.The need for the MAR to be accurate was discussed with Staff 12 (ED/Administrator) and Staff 11 (Operations Director) on 08/23/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 2 sampled residents (#s 11 and 12) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 11 was admitted to the facility in 09/2020 with diagnoses including Addison's Disease. Review of the resident's 11/01/22 through 12/04/22 MAR and 09/07/22 signed physician orders revealed the following: PRN Oxycodone and Acetaminophen were both prescribed for pain. The MAR lacked instruction to unlicensed staff regarding which medication to administer first. A PRN Epinephrine pen was prescribed by the physician to treat an allergic reaction. The instructions on the MAR directed staff to "use as directed", but lacked further resident specific information or instruction to staff. *Alprazolam, ordered twice daily for anxiety, lacked instruction to staff regarding how far apart the doses could be administered.The need to ensure the MAR was accurate, included parameters and resident specific instructions for the administration of PRN medications was discussed with Staff 12 (ED/Administrator) and Staff 19 (RN) on 12/06/22. They acknowledged the findings. 2. Resident 12 was admitted in 09/2020 with diagnoses including asthma. The resident's current physician orders and 11/01/22 through 12/04/22 MAR were reviewed. Resident 12's physician orders indicated the resident was to be administered albuterol sulfate via nebulizer PRN for asthma. There were no resident specific instructions on the MAR as to the signs and symptoms which would necessitate administration of the medication. The need to ensure the MAR was accurate, included parameters and resident specific instructions for the administration of PRN medications was discussed with Staff 12 (ED/Administrator) and Staff 19 (RN) on 12/06/22. They acknowledged the findings.
Plan of Correction:
1.MAR has been reviewed it has been determined that two of the creams are no longer being used and a request to discontinue has been sent to the Resident #5's PCP. Staff have been retrained to document when providing treatments.2.All staff involved in the management of medications and treatments will receive additional training regarding accuracy, documentation requirements, improved overall communicatio, Medication Administration/ Treatment administartion records will be randomly reviewed by The resident Care Coordinator to identify errors in documentation or lack there of.3.Any errors or holes in Mars will be reviewed timely with the employee and will be reviewed, in depth, at least quarterly via quality iimprovement program for patterns and the need for additional training. 4.Compliance is assured by Resident Care Coordinator, Licensed Nurse/Executive Director.C310-Medication Administration1.Resident #7 MAR has been corrected to include parameters for bowel medications and order for eye drops has been added to the MAR. History of pharmacy orders for B-12 injection was given but not documented, this has been corrected in the MAR.Resident #9 MAR has been corrected to reflect parameters of order to be given for prescribed bowel medications.Resident #6 under review with hospice to determine effectiveness of pain medications. Parameters will be written on new order by hospice. Hospice will include training for staff of signs and symptoms of overdose and will provide instructions on administering Naloxone. Nurse consultant will be coordinating with hospice and providing additional training staff. Resident #6 MAR has been corrected with Fentanyl patch site placement. Resident #8 The Med Tech will receive documented training by Licensed nurse on sliding scale insulin.2. Ongoing documented training for all med techs.3. The Mar will be evaluated daily M-F during clinical meetings and during shift change. 4. RCC and RN responsible for ensuring compliance.C310-Medication Administration1. Resident #11 MAR has been corrected to include: order of administration for Oxycodone and Acetaminophen, detailed instructions for Epinephrine pen, and parameters for Alprazolam. Resident #12's MAR has been updated to include: resident specific instructions with signs/symptoms to necessitate administration of medication. 2.The MAR will be evaluated daily M-F during clinical meetings and during shift change.3.The MAR will be reviewed daily-M-F, monthly, quarterly 4.The Resident Care Coordinator and Registered Nurse will be responsible for reviewing and monitoring to ensure compliance.