| 50 |
BELLA TERRA OF BILLINGS |
275020 |
1807 24TH ST W |
BILLINGS |
MT |
59102 |
2018-06-14 |
755 |
E |
1 |
1 |
JJY911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to maintain an accurate Narcotic Log Record, which reflected the medications administration count of controlled medications for 3 (#s 7, 52, and 234) of 31 sampled and supplemental residents; the facility failed to maintain an accurate Controlled Substance Record which reflected the physician ordered medications for 1 (#59) of 31 sampled and supplemental residents; and failed to timely administer a controlled substance that had previously been signed out as administered for 1 resident (#50) of 19 sampled residents. Findings include: 1. Inaccurate Controlled Substance Record: a. During an observation on 6/13/18 at 1:58 p.m., staff member M reviewed the medications in the narcotic lock box of the Rehab One Medication Cart. A comparison of the Narcotic Log Book, page 30, with the medication card numbered 30, showed a discrepancy. The Narcotic Log Book showed resident #7's Sildenafil 20 mg tablets, had a count of 5 remaining. The medication card, numbered 30, for resident #7's Sildenafil 20 mg tablets, showed a count of 4 tablets remaining. Review of resident #7's EMAR showed one, Sildenafil 20 mg tablet, was administered to the resident on 6/13/18 at 11:00 a.m. During an interview on 6/13/18 at 2:17 p.m., staff member M stated she had prepared resident #7's Sildenafil tablet at 11:00 a.m., that day, not realizing the resident had left the facility. She stated she had already signed the medication as given on the EMAR at 11:00 a.m. She said she did not give the medication to the resident until around 2:00 p.m., when the resident returned to the facility. She stated the facility's expectation was not to sign out medication before they were given to the resident. She stated she must have forgot to sign the Sildenafil out of the Narcotic Log Book after she removed the pill from the blister pack in the narcotic lock box. She stated all controlled medications should be signed out in the Narcotic Log Book immediately after removing them from the lock box for administration. b. During an observation on 6/13/18 at 2:26 p.m., staff member N reviewed the medications in the narcotic lock box of the Rehab Two Medication Cart. A comparison of the Narcotic Log Book, page 28, with the medication card numbered 28, showed a discrepancy. The Narcotic Log Book showed resident #234's [MEDICATION NAME] HCL 2 mg tablets, had a count of 15 tablets remaining. The medication card numbered 28, for resident #234's [MEDICATION NAME] HCL 2 mg tablets, showed a count of 16 tablets remaining. Review of resident #234's EMAR showed the resident was administered [MEDICATION NAME] 2 mg on 6/13/18 at 11:01 a.m. During an interview on 6/13/18 at 2:26 p.m., staff member N stated she must have forgot to sign the medication out in the Narcotic Log Book earlier that day. She stated it was the expectation to sign out the medication in the Narcotic Log Book immediately after dispensing the medication from the lock box. During an interview on 6/13/18 at 3:12 p.m., resident #234 stated she felt her pain was well managed by the staff, and had no concerns with not being able to get her pain under control. She stated once pain medication was given as ordered, it worked quickly. During an interview on 6/13/18 at 3:00 p.m., staff member B stated it was the expectation all controlled medications were accounted for in the Narcotic Log Book. She stated the Narcotic Log Book should accurately reflect what was remaining in the medication card for each resident. She stated any discrepancies should be reported to the nurse manager. She stated it was not an acceptable method to administer a controlled medication and sign it out at a later time. The staff member stated it was also not acceptable to prepare a medication, sign it out in the EMAR as administered, and give the medication at a later time than the time it was signed out as administered. During an interview on 6/14/18 at 9:16 a.m., staff member O stated he performed a 10% audit of the controlled medications once a month. He stated an audit was also conducted by the nursing quality review when the new administration became effective in (MONTH) (2018). He said they conducted a thorough audit of all the Narcotic log books and narcotics in the facility. He said a review of both audits, had no incidents of concerns with discrepancies between the two. c. During an observation on 6/13/18 at 1:45 p.m., staff member G was preparing medications for resident #52. Staff member G looked at the medication record, looked at the narcotic book for resident #52, and obtained a blister pack of medication for resident #52 out of the narcotic drawer. Staff member G popped the medication out of the blister pack and showed the card to the surveyor. Staff member G started to sign out the narcotic medication in the narcotic book. It was observed that the narcotic count was incorrect. The medication taken out of the blister pack was different than the medication in the blister pack and there was white tape placed on the back of the medication blister pack where staff member G had removed the medication. The medication staff member G removed was light pink in color and the medication in the blister pack was dark purple in color. During an interview on 6/13/18 at 1:45 p.m., staff member G stated she counted the narcotics with staff member R when she came on shift. She stated the narcotic count was right. She said she did not look at the book when she counted that morning. Staff member G stated she had only looked at the blister pack and staff member R looked at the narcotic book. Staff member G called for staff member C to inform her of the findings. During an interview on 6/13/18 at 2:25 p.m. staff member Q stated during the narcotic count, they normally call the page number out and one nurse looked at the narcotic book while the other nurse looked at the blister pack. She stated neither nurse looked at both the blister pack and the book. During an interview on 6/14/18 at 10:00 a.m., staff member C stated staff members G and R were both suspended pending an investigation. A review of the facility's policy and procedure titled, Controlled Medications Count, showed: It is the policy of the facility to maintain an accurate count of Scheduled II and controlled medications. 1. After removing the controlled medication from the blister pack or the individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the EMAR. 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication. 2. Inaccurately Transcribed Order: During an observation on 6/13/18 at 1:58 p.m., staff member M reviewed the medications in the narcotic lock box of the Rehab One Medication cart. A comparison of the Narcotic Log Book, pages 57 and 59, with the medication cards numbered 57 and 59, showed a discrepancy. The medication cards showed resident #59 was to receive [MEDICATION NAME] 50 mg tablet, give half of a tablet (25 mg), by mouth every six hours, PRN pain. A review of the Narcotic Log Book pages 57 and 59, showed the order was written, [MEDICATION NAME] 25 mg tablet, give half of a tablet for a total of 12.5 mg, every six hours, PRN pain. Review of resident #59's Physician Orders, dated (MONTH) (YEAR), showed an order for [REDACTED]. During an interview on 6/13/18 at 1:58 p.m., staff member M stated she was not sure who had transcribed the order from the card into the Narcotic Log Book. She stated she had not noticed the discrepancy between the two, even after completing the narcotic count with the outgoing nurse. She stated it was the facility policy that a second nurse check the orders and the transcription of the medication card into the Narcotic Log Book for accuracy. She stated there was a time when the facility did not have enough staff and there was not always a second nurse to check the accuracy of the nurse transcription into the narcotic logs. During an interview on 6/13/18 at 4:33 p.m., staff member B stated it was the expectation the Narcotic Log Book accurately reflect the medication as on the medication card and the physician order. She stated it was the expectation the nurses double check the new order after it was transcribed into the Narcotic Log Book. 3. Narcotic Medications Recorded as Given but not Administered: During an observation on 6/13/18 at 2:00 p.m., a medication count was conducted of the narcotics on the medication cart and refrigerator on the Mountain View Hall, with staff member T. The count showed the number of [MEDICATION NAME] 0.5 mg tabs contained in the narcotic card, held in the cart, for resident #50 was 29. At the same time, the corresponding narcotic record for the [MEDICATION NAME] showed 28 tabs should still be contained in the card. The card was counted a second time by staff member T, and he verified the count was over by one, which was an [MEDICATION NAME] 0.5 mg tablet. Staff member U had signed out the last dose of [MEDICATION NAME], which was given at 10:10 a.m. that morning. During an interview on 6/13/18 at 2:00 p.m., staff member U reviewed the narcotic card and narcotic record counts. She said she had participated in the narcotic count at shift change in the morning and that it had been correct. She said she must not have poured an [MEDICATION NAME] 0.5 mg tab into the medication cup she had prepared for resident #50 at 10:10 a.m. She poured an [MEDICATION NAME] 0.5 mg tab into a disposable medication cup and crossed out the 10:10 a.m. time on the narcotic record, wrote above it 2:00 p.m., and proceeded to go to resident #50's room and gave resident #50 the [MEDICATION NAME] tablet. Staff member U stated she would provide a copy of the medication error report to the survey team when she completed it. The report was not received by the end of the survey. |
2020-09-01 |