| 15 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2018-05-17 |
755 |
E |
0 |
1 |
FGZ511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to maintain a system that recorded, reconciled, and monitored the accountability and accuracy of dispensing [MEDICATION NAME], a narcotic medication, and failed to maintain accurate Medication Administration Record [REDACTED]. Findings include: During an observation and interview on 5/16/18 at 8:32 a.m., staff member C opened a locked cabinet in the medication room of the East View campus. Staff member C stated the Narcotic Lock Box, also known as an E-Kit, was kept inside the cabinet. The E-Kit was on the top shelf of the cabinet, and had a red plastic padlock seal. The numbers on the lock ended in 573. Staff member C stated the plastic padlock seal numbers should have ended in 525. Staff member C reviewed the E-Kit log, and stated the correct number for the new lock had not been recorded when the E-Kit was last inventoried. At 8:41 a.m., Staff members C and F discovered six doses of [MEDICATION NAME] were missing from the E-Kit. A review of the facility's E-Kit Record, dated 8/24/17 to 5/16/18, showed the last date staff had accessed the E-Kit was on 3/28/18, for an Inventory Check. During an interview on 5/16/18 at 8:52 a.m., staff member C stated staff should have verified the accuracy of the E-Kit by documenting the date, time, tag number when sealed (padlock seal), name of the item removed/added, along with two nursing signatures to ensure accuracy. Staff member C stated staff should have sent a facsimile to the pharmacist showing what had been removed/added. Staff member C stated the Narcotic Lock Box Record had a listing of information required when accessing the locked box. Staff member C stated she was not sure what happened to the [MEDICATION NAME], was not sure if the missing tablets had been administered to a resident, and to which resident the [MEDICATION NAME] had been administered to. During an interview on 5/16/18 at 12:21 p.m., staff member F stated she had contacted the nurses working within the past month on the East view campus. Staff member F stated she spoke with the nurse that did not document the [MEDICATION NAME] doses removed from the E-Kit. Staff member F stated she also called the pharmacy to inquire which resident on the East View campus had been started on [MEDICATION NAME] around that same time frame. Staff member F stated the [MEDICATION NAME] had been dispensed to resident #75. Review of resident #75's (MONTH) (YEAR) MAR indicated [REDACTED] 1. [MEDICATION NAME] 50 mg one tablet by mouth every 4 hours as needed, may couple with [MEDICATION NAME] 325 mg. Dated 4/13. Resident #75's MAR indicated [REDACTED]. A review of resident #75's Physician's Telephone Orders, dated 4/13/18, showed orders to Start [MEDICATION NAME] 50 mg- one by mouth every 4 hours for pain. (MONTH) couple with [MEDICATION NAME] 350 mg- one for additional [MEDICATION NAME] effect. #60 and 5 refills. A review of the resident #75's Narcotic Record in the Controlled Substance Record binder, dated 4/16/18 at 12:45 a.m., showed resident #75 was administered [MEDICATION NAME], one tablet by mouth, for pain. The remaining tablets were documented as 59. On 5/11/18 at 3:50 a.m., resident #75 was administered [MEDICATION NAME], one tablet by mouth, for pain. The remaining tablets were documented as 58. On 5/11/18 at 7:50 a.m., resident #75 was administered [MEDICATION NAME], one tablet by mouth, for pain. The remaining tablets were documented as 57. Review of resident #75's medical record, including the (MONTH) (YEAR) MAR, E-Kit, and Controlled Substance Record lacked evidence showing [MEDICATION NAME] had been removed from the E-Kit and had been dispensed to resident #75. During an interview on 5/16/18 at 12:27 p.m., staff member F stated nursing staff had not, but should have, started a new sheet in the Controlled Substance Record binder. Staff member F stated nursing staff were required to start a new page in the Controlled Substance Record when dispensing new narcotic medications to any resident. During an interview on 5/17/18 at 10:00 a.m., staff member D stated she had not been informed of staff failing to document missed doses of [MEDICATION NAME] signed out to resident #75. Staff member D stated she had been told there were discrepancies with the [MEDICATION NAME] in the E-Kit. Staff member D stated staff should have documented the [MEDICATION NAME] in the E-Kit record, in resident #75 MAR, and on the Controlled Substance Record. Staff member D stated she would ensure a thorough investigation would be conducted since [MEDICATION NAME] is a narcotic medication. Review of an Investigation of missing [MEDICATION NAME], dated 5/16/18, read, (staff name) started the investigation- called the pharmacy to see which resident had been started on [MEDICATION NAME] in the last month- there were 2 residents, one had his card the other did not- (staff name) reports writing the verbal order for the [MEDICATION NAME] late in the afternoon- (name) called nurses about taking [MEDICATION NAME] out of the E-kit on or around the date of the resident (without the card) starting [MEDICATION NAME]- discovered a nurse had taken them for the resident- they were not signed out- several nurses did not sign out the PRN medication on the MAR- there is no proof of using the [MEDICATION NAME] on the resident except for nurses stating that they administered the [MEDICATION NAME] to the resident. A review of the facility's policy, Medication Storage and Handling, read, Medication storage is designed to assist in maintaining medication integrity, promote the availability of medications when needed, minimize the risk of medication diversion, and reduce potential dispensing error .C. All drugs removed from a medication storage area are removed just prior to administration and only for one patient (sic) at a time. |
2020-09-01 |