| 85 |
ST JOHN'S LUTHERAN HOME |
275024 |
3940 RIMROCK RD |
BILLINGS |
MT |
59102 |
2019-03-08 |
761 |
E |
0 |
1 |
SJ2F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the supply of Schedule III-V medications were kept to a minimal level; and failed to ensure the Schedule III-V medications were separately locked; and not locked under the same access system used to obtain non-scheduled medications. The above practices had the potential to affect all residents with Schedule III-V medications stored and maintained at the facility. Findings include: During an observation and interview on 3/6/19 at 9:15 a.m., an opened 30 ml bottle of [MEDICATION NAME], a Schedule IV medication, was observed in the refrigerator in the medication room. The refrigerator did not have a separate locking mechanism. Staff member N stated the medication room had a lock, but the refrigerator did not. Staff member N stated the main door to the nursing area needed to be locked if the nurse left the area, but the nurse needed to have a visual on the room if they stepped out. Staff member N stated, We do not count [MEDICATION NAME]. During an interview and observation on 3/6/19 at 12:50 p.m., staff member H stated [MEDICATION NAME], if in liquid form, was in the refrigerator, locked in the closet in the nurses' room. The staff member unlocked the closet door to show where the refrigerator was located. The refrigerator had a clasp and lock, but was not locked. The staff member stated [MEDICATION NAME] and [MEDICATION NAME] were not double locked in any of the facility cottages. Residents with orders for [MEDICATION NAME], in a pill form, or [MEDICATION NAME], had the medications secured with a single lock system, which was in a cabinet, in the resident's room. These medications were not counted in the same manner as the the narcotics and PRN (as needed) medications. Staff member H showed where a resident's single locked medication cabinet was located. The staff member unlocked the cabinet and showed where the resident's [MEDICATION NAME] was located. During an observation and interview on 3/6/19 at 1:10 p.m., staff member P demonstrated the location of a card of PRN [MEDICATION NAME]. The card was located in the main compartment of the medication cart with the non-scheduled medications. Staff member P stated, We were taught that only narcotics get locked and counted, not [MEDICATION NAME]. Only things like [MEDICATION NAME], and [MEDICATION NAME] get locked and counted. During an interview and record review on 3/7/19 at 10:00 a.m., staff member C stated that Schedule III-V medications are in a different category than Schedule II medications and there are different dispensing laws for Schedule II medications. When discussing if the facility practiced double locking all controlled substances, staff member C stated, I believe they are. Staff member C stated, I would recommend to double lock Schedule III-V medications if we were meeting to determine policy. Staff member C said the facility had one episode of missing controlled substances reported to the DE[NAME] Review of the facility document, Loss of Controlled Substances at (facility name), not dated, showed an outline of an investigation for the loss of twenty eight [MEDICATION NAME] tablets, and [MEDICATION NAME], on 11/16/18. During an observation on 3/7/19 at 1:33 p.m., three, pre-filled cards of [MEDICATION NAME] 50 mg TID, were found in the medication cart. Each card held up to thirty tablets, and were labeled with a sticker indicating the time of day the card was to be used. The cards with the [MEDICATION NAME], a Schedule IV medication, were located with the other non-scheduled medications in the cart, and were not separately locked. During an interview and observation on 3/8/19 at 7:40 a.m., staff member I stated the long term care cottages did not count [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME], or [MEDICATION NAME] as narcotics, and were not counted at the change of shift. The staff member stated these medications were located in the residents' rooms, along side non scheduled medications. The staff member showed where the narcotics were located in the nurses room, in a stationary cupboard, inside a locked closet. The staff member stated for the medications discussed, if there was a physician's orders [REDACTED]. The cupboard had a single lock. Staff member I stated the facility was the only place where she had worked that did not require the above named medications be counted during shift change. During an interview on 3/8/19 at 8:01 a.m., staff member B said the facility did not double lock Schedule III-V medications because the DEA has different dispensing rules for those medications, than for Schedule II medications. Staff member B said the facility double locks and counts every Schedule II medication, each shift. In reference to the Schedule III-V medications, staff member B stated, There are only nurses and med aids, and they are not messing with narcotics at all. Staff member B said she misspoke the other day (3/7/19), when she said they did not have any issues with missing medications. Staff member B described the incident of missing [MEDICATION NAME] and missing [MEDICATION NAME], which occurred on 11/16/18, stating the facility investigated the incident and reported it to the DE[NAME] A review of the facility document titled Loss of Controlled Substances at (facility name), not dated, showed, It is the consensus of the DON, HR Director and Pharmacy Director that the [MEDICATION NAME]/APAP and [MEDICATION NAME] are lost. They do not suspect theft because of the long term employment of the staff members involved and the solid answers they gave during the interview which were consistent with the available security video. As a result, police were not called, but a DEA 106 for (sic) is being submitted. Review of facility policy titled Ordering And Receiving Controlled Medications, dated 10/1/12, showed, The pharmacy dispenses medications listed in Schedules II, III, IV and V in readily accountable quantities and containers designed for easy counting of contents Medications listed in Schedule III, IV, and V are stored under single lock. Alternatively, in a unit dose system, Schedule III, IV and V medications may be distributed with other medications throughout the cart, while Schedule II medications are kept under double lock. |
2020-09-01 |