cms_DE: 92
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 92 | BRANDYWINE NURSING & REHABILITATION CENTER | 85004 | 505 GREENBANK ROAD | WILMINGTON | DE | 19808 | 2017-07-19 | 431 | E | 1 | 1 | ZBS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record reviews, interviews, review of facility documentation and the manufacturer's medication guide, it was determined that for 6 (R17, R38, R136, R142, R152, R88) out of 55 Stage 2 sampled residents, the facility failed to provide pharmaceutical services to meet the needs of each resident. It was determined that for 5 (R17, R38, R136, R142 and R152) out of 5 residents who were prescribed Vimpat, a controlled medication used for seizure disorders, the facility failed to have an effective system using the Controlled Drug Receipt/Record/Disposition Forms (accountability records) that accurately accounted for, reconciled and recorded the disposition of controlled medications. In addition, the facility failed to dispose of R17's remaining Vimpat medication 72 hours after she was discharged from the facility in accordance with the facility pharmacy policy. For R88, the facility failed to ensure the correct labeling of a medication in accordance with currently accepted professional principles. Findings include: ,[DATE] - The Vimpat Medication Guide approved by the U.S. Food and Drug Administration (https://www.vimpat.com/vimpat-medication-guide.pdf) stated, .4. VIMPAT is a federally controlled substance . because it can be abused or lead to drug dependence . [DATE] - The facility pharmacy policy entitled, Controlled Medications stated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations .D. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration. 2) Amount administered. 3) Signature of the nurse administering the dose, completed after the medication is actually administered. E. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose. The same process applies to the disposal of unused partial tablets . [DATE] - The facility pharmacy policy entitled, Controlled Medication Disposal stated, .C. Destruction of .discharged or deceased resident controlled medication shall be jointly performed by two authorized licensed personnel within 72 hours of the discontinuation or discharge. D. A record of the destruction must be signed by both parties. This document becomes part of the resident's permanent medical record . Cross refer to F281, example 1 1a. Review of R17's clinical record revealed the following: [DATE] - R17 was admitted to the facility with [DIAGNOSES REDACTED]. [DATE] - A physician's orders [REDACTED]. Review of R17's accountability record for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Wednesday, [DATE], AM dose; - Thursday, [DATE], AM dose. [DATE] through [DATE] - R17 was hospitalized for [REDACTED]. [DATE] - A physician's orders [REDACTED]. Review of R17's accountability record for her Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Saturday, [DATE], AM dose; - Sunday, [DATE], AM dose; - Sunday, [DATE], PM dose. Review of R17's (MONTH) (YEAR) eMAR revealed that licensed nursing staff administered and signed off the 5 doses of Vimpat medication listed above. It was unclear why R17's accountability forms did not match her eMAR and account for the 5 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R17. 1b. R17 was sent to the hospital on [DATE] at 11:50 PM. [DATE] at 4:06 PM - A social service note stated that R17 passed away in the hospital on [DATE] and her family picked up her belongings on [DATE]. Review of R17's accountability form for her Vimpat medication revealed that from [DATE] through [DATE] a total of 14 tablets were signed out as wasted by either one or two licensed nurses. It was unclear why the facility failed to remove R17's Vimpat medication within 72 hours after she left the faciity on [DATE]. On [DATE] at 10:54 AM, surveyor met with E2 (DON) and E3 (RN/Staff Ed) to find out why 14 tablets of R17's Vimpat medication were signed off as wasted on her accountability record 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 [DATE] at 1:50 PM, E3 stated that licensed nursing staff administered R17's Vimpat medication to other residents, including R142. With the exception of R142, it was unclear on R17's accountability record the other residents who received the remaining 11 tablets. Findings were reviewed with E2 and E3 on [DATE] at 3 PM. The facility failed to dispose of her remaining Vimpat medication 72 hours after she was discharged from the facility in accordance with the facility pharmacy policy. 2. Review of R38's clinical record revealed the following: [DATE] - A physician's orders [REDACTED]. Review of R38's accountability record for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Thursday, [DATE], PM dose; - Friday, [DATE], AM dose. Review of R38's (MONTH) (YEAR) eMAR revealed that licensed nursing staff administered and signed off the 2 doses of Vimpat medication listed above. It was unclear why R38's accountability forms do not match her eMAR and account for the 2 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R38. 3. Review of R136's clinical record revealed the following: [DATE] - A physician's orders [REDACTED]. Review of R136's accountability records for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Friday, [DATE], PM dose; - Friday, [DATE], PM dose; - Saturday, [DATE], AM dose; - Saturday, [DATE], PM dose; - Sunday, [DATE], AM dose; - Sunday, [DATE], PM dose; - Monday, [DATE], AM dose. Review of R136's (MONTH) and (MONTH) (YEAR) eMARs revealed that licensed nursing staff administered and signed off the 7 doses of Vimpat medication listed above. It was unclear why R136's accountability forms did not match her eMAR and account for the 7 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R136. 4. Cross refer F281 example #2 Review of R142's clinical record revealed the following: [DATE] - A physician's orders [REDACTED]. Review of R142's accountability records for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Friday, [DATE], PM dose; - Saturday, [DATE], AM dose; - Saturday, [DATE], PM dose; - Sunday, [DATE], AM dose; - Sunday, [DATE], PM dose; - Monday, [DATE], AM dose; - Wednesday, [DATE], PM dose. Review of R142's (MONTH) (YEAR) eMAR revealed that licensed nursing staff administered and signed off the 7 doses of Vimpat medication listed above. It was unclear why R142's accountability forms did not match his eMAR and account for the 7 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R142. 5. Review of R152's clinical record revealed the following: [DATE] - A physician's orders [REDACTED]. Review of R152's accountability records for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - [DATE], PM dose; - [DATE], AM dose. Review of R152's (MONTH) (YEAR) eMAR revealed that licensed nursing staff administered and signed off the 2 doses of Vimpat medication listed above. It was unclear why R152's accountability forms did not match his eMAR and account for the 2 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R152. Findings were reviewed with E2 (DON) and E3 (RN/Staff Ed) on [DATE] at 3 PM. The facility failed to have an effective system in place using the Controlled Drug Receipt/Record/Disposition Forms (accountability records) that accurately accounted for, reconciled and recorded the disposition of controlled medications for 5 residents (R17, R38, R136, R142 and R152). In addition, the facility failed to dispose of R17's remaining Vimpat medication 72 hours after she was discharged from the facility. 6. During medication administration observation for R88 on [DATE] at 8:30 AM, it was observed that R88's Lantus Insulin was labeled incorrectly. The label stated the opposite, to inject 30 units subcutaneously in the morning and 10 units subcutaneously at bedtime. The physician's orders [REDACTED]. During an interview on [DATE] at 8:30 AM, E9 (LPN) confirmed that the Lantus Insulin was labeled incorrectly. The findings were reviewed with E2 (DON) and E3 (RN, Staff Development) on [DATE] at 2:45 PM. | 2020-09-01 |