| 84 |
BRANDYWINE NURSING & REHABILITATION CENTER |
85004 |
505 GREENBANK ROAD |
WILMINGTON |
DE |
19808 |
2017-07-19 |
281 |
D |
1 |
1 |
ZBS111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, interviews, review of the facility's pharmacy policies and the manufacturer's medication guide, it was determined that for 2 (R17 and R142) out of 55 Stage 2 sampled residents, the facility failed to provide services that met professional standards of quality. The facility failed to ensure that licensed nursing staff did not administer another resident's (R17) [MEDICATION NAME] medication, a controlled substance used for [MEDICAL CONDITION] disorders, to R142. Findings include: 8/14 - The [MEDICATION NAME] Medication Guide approved by the U.S. Food and Drug Administration (https://www.[MEDICATION NAME].com/[MEDICATION NAME]-medication-guide.pdf) stated, .4. [MEDICATION NAME] is a federally controlled substance (C-V) because it can be abused or lead to drug dependence .Never give your [MEDICATION NAME] to anyone else, because it may harm them .Take [MEDICATION NAME] exactly as your healthcare provider tells you .Do not give [MEDICATION NAME] to other people, even if they have the same symptoms that you have. It may harm them . 1/1/16 - The facility pharmacy policy entitled, Emergency Pharmacy Service and Emergency Kits stated, Emergency pharmacy service is available on a 24-hour basis .D. Medications are not borrowed from other residents . 1/1/16 - The facility pharmacy policy entitled, Medication Administration-General Guidelines, stated, Medications are administered as prescribed in accordance with good nursing principles and practices .B. Administration .2) Medications are administered in accordance with written orders of the attending physician .12) Medications supplied for one resident are never administered to another resident . Cross refer to F431, example 1 1. Review of R17's clinical record revealed the following: 5/25/17 - A physician's orders [REDACTED]. 6/2/17 at 10:15 PM - A nurse's note stated that R17 was sent to the emergency room at 11:50 PM. 6/8/17 at 4:06 PM - A social services note stated that R17 did not retun from the hospital on [DATE]. 6/9/17 through 6/19/17 - Review of R17's Controlled Drug Receipt/Record/Disposition Form (accountability record), issued by the pharmacy, revealed that a total of 14 tablets of R17's [MEDICATION NAME] 200 mg medication was signed out by one or two licensed nurses after R17 was discharged from the facility: - 6/9 at 8 PM - one tablet was signed out by two nurses and wasted was handwritten; - 6/10 at 9:30 AM - one tablet was signed out by one nurse and wasted was handwritten; - 6/10 at 8 PM - one tablet was signed out by two nurses with no reason given; - 6/11 at 8:01 AM - one tablet was signed out by one nurse and wasted was handwritten; - 6/11 untimed - one tablet was signed out by two nurses and wasted was handwritten; - 6/12 untimed - one tablet was signed out by two nurses and wasted was handwritten; - 6/12 untimed - one tablet was signed out by two nurses and wasted was handwritten; - 6/13 untimed - three tablets were signed out by two nurses and wasted was handwritten; - 6/17 untimed - one tablet was signed out by two nurses and wasted was handwritten; - 6/17 untimed - two tablets were signed out by one nurse and wasted was handwritten; - 6/19 untimed - one tablet was signed out by one nurse and wasted and R142's room number were handwritten. Cross refer to F431, example 4 2. Review of R142's clinical record revealed the following: 6/16/17 - A physician's orders [REDACTED]. Review of R142's (MONTH) (YEAR) eMAR revealed the following: - Saturday, 6/17/17, AM - E14 (LPN) signed off that R142 received [MEDICATION NAME] 150 mg tablet; - Sunday, 6/18/17, AM - E14 signed off that R142 received [MEDICATION NAME] 150 mg tablet; - Monday, 6/19/17, AM - E21 (LPN) signed off that R142 received [MEDICATION NAME] 200 mg tablet. Review of R142's clinical record revealed the absence of the accountability record for his [MEDICATION NAME] 150 mg medication. While R142's clinical record revealed the absence of the accountability record for his 6/19/17 AM [MEDICATION NAME] 200 mg dose, it was identified that the medication was taken from R17, a discharged resident, on 6/19/17 and recorded on R17's accountability record. On 7/18/17 at 10:54 AM, surveyor met with E2 (DON) and E3 (RN/Staff Ed) to find out why 14 tablets of R17's [MEDICATION NAME] medication were signed off as wasted on her Controlled Drug Receipt/Record/Disposition Form after R17 was discharged from the facility. E2 and E3 stated they would look into it and follow-up with surveyor. During a follow-up interview with E2 and E3 on 7/18/17 at 1:50 PM, E2 stated that [MEDICATION NAME] medication was not included in the facility's backup medication stock. E3 stated that licensed nursing staff used R17's [MEDICATION NAME] medication and administered her medication to other residents, including R142. During an interview on 7/19/17 at 9:35 AM, E14 (LPN) stated that R142 did not have [MEDICATION NAME] 150 mg tablet medication readily available to be administered the morning of 6/17/17. E14 stated that she called the pharmacy regarding R142's [MEDICATION NAME] medication. E14 stated that she performed an electronic computer search of all residents in the facility that were on [MEDICATION NAME] medication. E14 stated that she asked E9 (LPN), another nurse assigned to a different medication cart, for [MEDICATION NAME] medication. E14 stated that E9 gave her [MEDICATION NAME] 200 mg tablet from another resident (R17). E14 stated that she altered R17's [MEDICATION NAME] 200 mg tablet by cutting the unscored tablet and administered the altered medication to R142. When asked if she notified the House Supervisor regarding the absence of R142's [MEDICAL CONDITION] medication availability over the weekend, E14 stated no. During an interview on 7/19/17 at 9:52 AM, E9 stated that E14 asked her for [MEDICATION NAME] medication. E9 stated that she removed, signed off as wasted on R17's [MEDICATION NAME] accountability record and gave two tablets (200 mg each) of R17's [MEDICATION NAME] medication to E14 for R142. E9 confirmed her signature on R17's accountability record for 2 tablets of [MEDICATION NAME] on 6/17/17. Findings were reviewed on 7/19/17 at 3 PM with E2 and E3. The facility failed to provide services that met professional standards by ensuring that licensed nursing staff did not administer another resident's (R17) [MEDICATION NAME] medication, a controlled substance used for [MEDICAL CONDITION] disorders, to another resident, R142. Additionally staff provided incorrect information on the accountability record. |
2020-09-01 |