cms_AZ: 3554
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3554 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2015-05-06 | 431 | E | 0 | 1 | CBHN11 | Based on observations, staff interviews, facility documentation, and review of the manufacturer's instructions and facility policies, the facility to ensure that medication was stored properly, failed to reconcile the narcotic emergency kit (E-kit) and failed to ensure narcotics on one medication cart were reconciled from shift to shift. Findings include: -An observation on (MONTH) 6, (YEAR) of the Malachite medication cart revealed an unopened box of Humalog Insulin, with a sticker on the box that stated refrigerate until opened. An interview was conducted on (MONTH) 6, (YEAR), with a License Practical Nurse (LPN) who stated that the insulin bottle should be placed in the refrigerator until needed, as there was already an opened bottle in the medication cart. A review of the manufacturer's instructions for the insulin revealed to store all unopened (unused) Humalog in the original carton in a refrigerator at 36 degrees to 46 degrees Fahrenheit. According to the facility's policy titled Storage of Medications included that Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secure location. -The medication storage task was conducted on (MONTH) 6, (YEAR) at 2:30 p.m. on the Malachite unit, with a licensed nurse. Inside the locked medication room was a narcotic E-kit, which was locked with a plastic numbered lock on each end. The license nurse was questioned regarding the facility's process for reconciling the plastic numbered locks on the narcotic E-kit from shift to shift, in order to determine if the E-kit had been accessed during the shift. The nurse stated that the nurses do not complete a shift to shift count on the narcotic E-kit. The nurse stated the E-kit was only to be opened if the nurse sent the pharmacy the script and then two nurses must be present when opening the E-kit. An interview was conducted with the Director of Nursing (DON) on (MONTH) 6, (YEAR), who stated the pharmacy picks up the E-kit and replaces the missing medication and that there was not a policy for the E-kit reconciliation. The facility was unable to provide any evidence that the numbered locks on the E-kit were being reconciled shift to shift, in order to determine if the E-kit had been accessed. A review of the facility's policy on Emergency Medication Supplies revealed that facility staff should review the Emergency Medication Supply for correct quantity and should immediately report to Pharmacy any discrepancies in quantity. -The medication storage observation was conducted on (MONTH) 6, (YEAR), of the (MONTH) (YEAR) Controlled Substance Count Verification/Shift Sheet for the Malachite cart. The narcotic count revealed there were seven staff signatures that were missing, indicating that the narcotic count was not completed from shift to shift. An interview was conducted with a LPN immediately following the observation. The LPN stated the Daily Narcotic and Controlled Drug Count Log should be signed each shift by the nurse going off shift and the nurse coming on shift, to verify that the narcotic count is accurate. A review of the facility's policy on Inventory Control of Controlled Substances revealed the facility should ensure that the nurses count all Scheduled II controlled substances and other medications with a risk of abuse or diversion at the change of each shift and document the results on the Controlled Substance Count Verification/Shift Count Sheet. | 2018-10-01 |