cms_GA: 89
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 89 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 431 | E | 0 | 1 | FY6A11 | Based on observation, record review, review of the policy titled Controlled Substance and staff interviews, the facility failed to ensure that a controlled substance, Lorazepam (Ativan) liquid injection, was accounted for in two of four medication storage refrigerators (West Wing Medication Storage Room and Dogwood/Georgia Medication Storage Room). The resident census was 35. Findings include: Review of the policy titled Controlled Drugs dated (MONTH) 2005 and revised (MONTH) 2011 documented: To ensure that controlled drugs are inventoried and administered as required by State and Federal agencies: Maintain a declining inventory record by resident by drug on all controlled drugs. Reconcile the declining inventory record at the beginning and the end of each shift. Reconciliation is performed by a physical count of the remaining medication by two persons who are legally authorized to administer medications. 1. Observation of the West Wing medication storage room on 11/2/17 at 1:50 p.m. revealed a locked refrigerator that when opened by staff contained commonly used medications and a controlled substance, Lorazepam (Ativan) liquid injectable. Observation with Licensed Practical Nurse (LPN) CC revealed a plastic package with four vials of Ativan. The label read; two milligrams per milliliter (2 MG/ML), Inject 1 MG (0.25 ML) intramuscularly every four hours as needed, prescribed to R#201. Review of the Controlled Substance Accountability Sheet with LPN CC revealed the last dated entry of dispense was 10/31/17 with a remaining quantity of five vials. LPN CC and the Unit Manager, LPN DD looked in the refrigerator and were unable to locate the fifth vial of Ativan. Interview on 11/2/17 at 1:58 p.m. with LPN CC revealed she had not conducted a count of the Ativan in the West Wing medication storage refrigerator because the night shift nurse had to leave early due to an emergency. LPN CC stated that the second night shift nurse, LPN EE told her that they had counted narcotics prior to the nurse leaving early. LPN CC confirmed that she signed the Change of Shift Controlled Substances Count Sheet but that she had only counted the narcotics in her assigned medication cart, but not the narcotics in the medication storage refrigerator. Interview on 11/2/17 at 2:24 p.m. with the Unit Manager, LPN DD revealed that if the night shift nurse left early, it would not negate a narcotic count and that LPN CC should have counted the Ativan in the refrigerator with another nurse at the beginning of her shift. Interview with the Director of Nursing (DON) on 11/2/17 at 3:55 p.m. revealed that after an investigation, it was discovered that on 10/28/17 R#201 was having seizures and LPN CC administered Ativan. The DON stated that LPN CC never signed out the Ativan on the Controlled Substance Accountability Sheet on 10/28/17 and did not record the administration of the Ativan on the Medication Administration Record [REDACTED]. The DON stated that if the nurses had been conducting narcotic counts as they are supposed to each shift, the discrepancy would have been discovered on 10/28/17 during the 3:00 p.m. count. The DON confirmed that the nursing staff had been signing off with their signatures on the Change of Shift Controlled Substances Count Sheet, that narcotic counts had been conducted. Review of the Progress Note dated 10/28/17 created by LPN CC at 2:50 p.m. documented: Writer called to resident bedroom at 1:17 p.m. and observe him having a seizure. Timed activity for a full minute. Ativan adm IM. Resident made comfortable. He seemed to quiet down but started seizing again. Shift Supervisor called to room to observe behavior. (Name) hospice nurse called, order to provide comfort measures or send him to their house facility. Resident finally calmed down after several episodes of seizures. VS 112/64, 66, 18, 97.5 (sic) Further review of the Change of Shift Controlled Substances Count Sheet revealed numerous signed signatures from the Nurse Departing from Duty and the Nurse Arriving on Duty indicating that all narcotics had been accounted for on the following dates and times: 10/28/17 at 3:00 p.m., 11:00 p.m., 10/29/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/30/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/31/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 11/1/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m. and 11/2/17 at 7:00 a.m. A total of 15 shift narcotic counts were documented by nurses indicating that five vials of Ativan prescribed to R#201 was remaining, after a vial was dispensed without record on 10/28/17, leaving only four vials of Ativan. Interview with the Consulting Pharmacist (CP) on 11/3/17 at 1:55 p.m. revealed she does conduct random audits and selects random medication carts. She stated she checks the control sheet for narcotics and ensures that the medication count matches what is on the control sheet. The CP further stated she does check the narcotics in the medication storage refrigerators but only to check for expiration dates and the correct amount of medication. She stated she does not check for the accuracy of the pharmacy label to ensure that it matches the facility's Physician order. Interview on 11/3/17 at 3:45 p.m. with LPN GG confirmed that her signature was on the Change of Shift Controlled Substances Count Sheet between 10/28/17 and 11/2/17. LPN GG stated she counts the narcotics on the medication cart first, then counts the narcotics in the medication storage refrigerator. LPN GG stated that she cannot recall how many vials of Ativan was in the labeled bag prescribed for R#201. Interview on 11/3/17 at 3:55 p.m. with Registered Nurse (RN) HH revealed her signature is on the Change of Shift Controlled Substances Sheet between 10/28/17 and 11/2/17. RN HH revealed that on 10/28/17 (3:00 p.m. - 11:00 p.m.), she started narcotic count on the medication cart but then she received a new admission, then a call from hospice that needed information on a resident and she just got distracted and never made it to the refrigerator to count the Ativan. RN HH stated she should have conducted a narcotic count in the West Wing medication storage refrigerator and that is the protocol but she was just really busy that day at that particular time. Interview on 11/3/17 at 6:07 p.m. with LPN EE revealed she was working on the nightshift (11:00 p.m. - 7:00 a.m.) on 11/1/17 through 11/2/17. She stated that LPN FF was working that evening with her and had to leave early at 6:30 a.m. She stated that she and LPN FF conducted a count of the med cart narcotics, but they had not counted the narcotics in the West Wing medication storage refrigerator. LPN DD stated that the protocol does include counting the narcotics in the refrigerator and it was just overlooked. 2. Observation of the medication storage refrigerator on 11/2/17 at 3:20 p.m. in the Dogwood/Georgia medication storage room revealed a 20MG/10 ML (20 milligrams per 10 milliliters) vial of Ativan prescribed to R#138. The vial did not have graduation marks but appeared to have a 1/4 of liquid Ativan remaining. Review of the Controlled Substance Accountability Sheet indicated that 0.5 ML had been dispensed 10 times on 8/11/17 at 10:00 a.m. and 6:00 p.m., 9/19/17, 9/20/17, 9/21/17, 10/15/17, 10/16/17, 10/21/17, and 10/22/17 at 10:00 a.m. and 5:00 p.m., with 5 ML quantity remaining. Interview on 11/2/17 at 3:25 p.m. with the Unit Manager, LPN JJ revealed that there is no way to measure how much Ativan liquid remains in the 10 ML vial and stated It looks like 5 ML to me. LPN JJ further stated he's never had any problems in the past with the vials coming up short once all doses had been administered. He stated that he called pharmacy and told them that there was no way they could keep track of the Ativan amounts from the 10 ML multi use vial and they were supposed to fix it. Observation with LPN JJ of an unopened 20MG/10 ML Ativan vial was held next to the opened vial. The unopened vial liquid reached the top of the wrap around label and the opened bottle was clearly less than half of the vial. LPN JJ confirmed that if the resident received ten 0.5 ML doses of the Ativan, there should have been 1/2 the liquid left (5 ML) and that the amount of liquid left was only about 1/4 full. Interview with the DON on 11/2/17 at 3:55 p.m. confirmed that with 20MG/10 ML vials of Ativan, there is no way to accurately measure how much Ativan is in the bottle once opened. She confirmed that according to the Controlled Substance Accountability Sheet, R#138 was administered 0.5 ML of Ativan injection 10 times and that there should be 5 ML remaining in the vial. The DON observed an unopened vial of Ativan liquid injection compared to the opened 10 ML vial prescribed to R#138 and confirmed it did not look like it was 1/2 full. The DON immediately removed the 20MG/10 ML vial of Ativan and instructed the Unit Manager, LPN JJ to write up a report, discard the medication and call pharmacy to have it replaced with 1 ML bottles. Interview on 11/3/17 at 12:40 p.m. with the DON revealed she has no way of knowing how much Ativan was in the 20MG/10 ML prescribed to R#138 so she wanted to have the remaining contents drawn up so she could be sure there was 5 ML of liquid remaining. The DON had a nurse come into the room and draw up the remaining Ativan in the 20MG/10 ml vial. The nurse announced once extracted by syringe that there was only 3 ML of Ativan left in the vial. The DON again confirmed that there should have been 5 ML remaining in the vial and there was no way to account for the missing 2 ML of liquid Ativan. | 2020-09-01 |