| 80 |
PIONEER CARE CENTER |
465020 |
815 SOUTH 200 WEST |
BRIGHAM CITY |
UT |
84302 |
2019-05-01 |
842 |
E |
1 |
0 |
OCVO11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 5 of 5 sample residents, that the facility did not maintain accurate documentation of medical records for each resident. Specifically, residents Medication Administration Records (MARs) and narcotic record logs did not match. Resident identifiers: 1, 2, 3, 4 and 5. Findings include: 1. Resident 2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 5/1/19. Resident 2's physicians orders revealed the following: a. On 3/7/19, [MEDICATION NAME] immediate 5mg (milligrams) tablet (1) tab (tablet) po (oral) Q (every) 4h (hours) prn (as needed) pain (times) 30. The telephone order had Licensed Practical Nurse (LPN) 1's signature. There was a stamp V.O.R.B. (verbal order read back) with the physicians signature and Drug Enforcement Administration (DEA) number. b. On 3/18/19, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tab. Give 1 tab po Q4 hours prn pain. The order had to dispense 60 tablets with no refills. The telephone order had a nurses signature with V.O.R.B stamped above it and the physicians signature with the DEA number. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] immediate 5mg every 4 hours as needed revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/6/19 at 12:30 AM, 3/7/19 at 8:00 PM, 3/8/19 at 5:00 AM and 3/12/19 at 6:30 AM. It should be noted that 4 doses were signed out on the narcotic record and were not signed out as administered on the MAR. The (MONTH) 2019 MAR revealed 3/9/19 at 1:25 AM that [MEDICATION NAME] was administered but the narcotic record sheet did not have the medication signed out. In addition, the MAR revealed that [MEDICATION NAME] 5 mg was administered on 3/27 at 4:27 PM and 3/31/19 at 5:59 PM. There was no corresponding narcotic record log in the medical record for the 2 doses. Review of the Narcotic Record Log entries with the corresponding MAR for [MEDICATION NAME] table 5-325 mg every 4 hours as need revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/14/19 at 10:30 PM, 3/15/19 at 2:30 AM, 3/20/19 at 6:00 AM, 3/20/19 at 9:00 AM, 3/22/19 at 6:00 AM, 3/23/19 at 11:00 PM, 3/25/19 at 6:00 AM, 3/26/19 at 3:00 PM, 3/26/19 at 7:00 PM, 3/27/19 at 4:50 PM, 3/28/19 at 3:00 AM, 3/31/19 at 6:00 PM, 3/31/19 at 10:00 PM, 4/3/19 at 5:00 AM, 4/4/19 at 2:40 AM, 4/4/19 at 9:30 PM, 4/5/19 at 5:00 PM, and 4/5/19 at 7:30 AM. It should be noted that 17 doses were signed out on the narcotic record and were not signed out as administered on the MAR. Review of the Narcotic Record Log entries with the corresponding MAR for [MEDICATION NAME] tablet 5-325 mg every 4 hours as needed revealed the following: a. On 3/30/19, the MAR revealed that the [MEDICATION NAME] was administered three times at 1:59 AM, at 1:38 PM and at 6:37 PM. The narcotic record revealed [MEDICATION NAME] was pulled and administered at 12:30 AM, no time, at 1:30 PM and at 6:30 PM. b. On 4/5/19, the MAR revealed that the [MEDICATION NAME] was signed as administered three times at 8:40 AM, at 1:55 PM, 7:44 PM. The narcotic record revealed [MEDICATION NAME] was pulled at 5:00 AM, at 7:30 AM, at 1:40 PM and at 7:45 PM. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 5/1/19. Resident 4's telephone orders revealed the following: a. On 1/25/19 at 4:35 PM, a verbal order for [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 MG give 1 tablet by mouth every 4 hours as needed for pain related to Generalized abdominal pain. The physician signed the order on 1/30/19 at 5:06 PM. There was no script in the medical record. The order was discontinued on 3/4/19. b. On 2/15/19, [MEDICATION NAME] 10/325 1 tab po Q4H PRN. The order was to dispense 120 with no refills. The MD signed with the DEA number on the telephone order. There was no nurses signature. There was a stamp of V.O.R.B. c. On 3/22/19, [MEDICATION NAME] tablet 10-325 M[NAME] Give 1 tablet Q 4 hours prn, NTE (not to exceed) 300 mg in 24 hr. Give 1 tablet po q 4 hours. NTE 3000mg in 24 hours. The order was to dispense 120 tablets with 3 refills. The MD signed with the DEA number on the telephone order. RN 1's signature with V.O.R.B was on the telephone order. Review of the Narcotic Record Log entries with the corresponding Medication Administration Record (MAR) for [MEDICATION NAME] 10/325 mg revealed that the medication was documented signed out on the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 2/23/19 at 7:25 AM, 3/9/19 at 10:30 AM, 4/7/19 at 12:00 PM, 4/11/19 at 9:00 PM, 4/12/19 at 9:00 PM, 4/14/19 at 1:20 PM, 4/15/19 at 9:55 PM, 4/18/19 at 9:00 PM, 4/26/19 at 6:45 PM and 4/28/19 at 9:00 PM. It should be noted that 10 doses were documented as administered in the narcotic log but not documented as administered in the MAR. Review of the Narcotic Record Log entries with the corresponding MAR for [MEDICATION NAME] 10/325 mg revealed the following: a. On 2/4/19 at 12:10 PM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 was administered and there was no record of the medication being administered on the narcotic record. b. On 2/22/19 at 11:33 AM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered and there was no record of the medication being administered on the narcotic record. c. On 3/21/19 at 6:00 AM, the MAR revealed that the nurse did not sign in the MAR that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered. The narcotic record revealed that on 3/20/19 at 5:30 AM and 3/2019 at 6:00 AM the medication was administered. d. 3/29/19 at 6:00 AM, the MAR revealed that the nurse did not sign that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered. The narcotic record revealed that on 3/29/19 at 6:00 AM the [MEDICATION NAME] was administered. 3. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/1/19 resident 5's medical records were reviewed. Review of resident 5's physician orders [REDACTED]. a. On 10/3/18, a telephone order for [MEDICATION NAME] Extended Release (ER) 10 milligrams by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. ( b. On 10/14/18, a telephone order for [MEDICATION NAME] (HCL) with Tylenol (APAP) 10/325 mg tablet, take 1 tablet by mouth every 6 hours as needed for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. c. On 10/25/18, a order for [MEDICATION NAME] HCL ER tablet, ER 12 hour Abuse-Deterrent 10 mg, 1 tablet by mouth two times a day for moderate to severe pain was written. The amount of medication ordered dispensed was 60 tablets. d. On 11/11/18, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. e. On 12/3/18, a telephone order for [MEDICATION NAME] HCL ER 10 mg 1 tablet by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. f. On 1/29/19, a telephone order for [MEDICATION NAME] 10/325 mg 1 tablet by mouth every 6 hours as needed was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. g. On 3/7/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. h. On 4/17/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by Registered Nurse (RN) 1. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL APAP 10/325 mg every 6 hours as needed revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 8/29/18 at 9:00 PM, 9/7/18 at 1:00 AM, 9/12/18 at 4:00 AM, 9/13/18 at 2:00 AM, 10/3/18 at 2:00 AM, 10/12/18 at 1:00 AM, 11/13/18 (day not documented clearly but located between 11/9/18 and 11/22/18) at 1:00 AM, 11/26/18 at 9:50 AM, 11/28/18 at 10:00 AM, 11/29/18 at 4:00 PM, 12/1/18 at 10:10 AM, 12/2/18 at 10:30 AM, 12/18/18 at 5:00 AM, 12/29/18 at 11:59 PM, 1/22/19 at 7:00 AM, 2/1/19 at 5:00 AM, 2/15/19 at 3:00 AM, 2/15/19 at 11:30 PM, 2/17/19 at 1:20 AM, 3/16/19 at 6:00 AM, 3/21/19 at 11:00 PM, 3/31/19 at 3:00 PM, 4/12/19 at 6:20 AM, 4/20/19 at 12:45 Am, 4/25/19 at 1:00 AM, 4/25/19 at 11:30 PM, and 4/30/19 at 11:00 PM. It should be noted that 27 doses were documented as administered in the narcotic log but not documented as administered in the MAR. Review of the Narcotic Record Log entries with the corresponding MAR for [MEDICATION NAME] Reformulated 10 mg tablet ER by mouth twice daily revealed the following: a. On 11/8/18 at 10:00 AM the medication was documented as refused and wasted. The narcotic log contained only one nurse signature for the wasted medication. b. The medication was documented as administered on the MAR but was not documented signed out on the narcotic log for the following dates; 11/26/18 at 7:00 AM to 11:00 AM (07-11), 11/28/18 at 07-11, 12/1/18 at 07-11, and 12/2/18 at 07-11. c. The medication was documented as administered on the MAR but was crossed out on the narcotic log for 1/24/19 at 9:30 AM. The medication was not documented as refused, was not documented as wasted, and was not deducted from the count. d. The medication was documented as administered on the MAR but was not documented as signed out on the narcotic log for 1/30/19 at 7:00 PM to 11:00 PM (19-23). e. The medication was documented as signed out in the narcotic log on 2/2/19 at 9:30 PM and then again at 9:45 PM. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. f. The medication was documented as signed out in the narcotic log on 2/8/19 at 1:00 AM the medication was scheduled for administration between 7:00 AM and 11:00 AM. The second daily dose was documented as administered in the narcotic log at 11:00 AM. g. The medication was documented as signed out in the narcotic log on 2/9/19 at 11:30 PM twice. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. h. On 4/13/19 at 19-23 the medication documented a code of HOLD see progress notes. Review of the progress notes revealed no documentation for this medication. The medication was documented as signed out in the narcotic log and was deducted from the medication count. On 5/1/19 at 12:30 PM an interview was conducted with the Director of Nursing (DON). The DON stated that the documentation in the narcotic record log and the MAR should match. The DON stated she did not know why the resident 5's MAR and narcotic record log did not match. 4. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was admitted to hospice on 1/3/19 for end of life cares, and passed away on 1/12/19. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that when a resident was on hospice, all of the resident's medications were provided by the hospice company. LPN 1 stated that the facility would create Narcotic Record sheets to track all hospice provided narcotics. On 4/30/19 resident 1's medical records were reviewed. Review of resident 1's physician orders [REDACTED]. a. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml (milliliters) 1ml by mouth every hour as needed for pain/shortness of breath. b. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.25ml by mouth every hour as needed for pain/shortness of breath. c. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.5ml by mouth every hour as needed for pain/shortness of breath. d. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.75ml by mouth every hour as needed for pain/shortness of breath. e. On 1/8/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 20mg/ml 0.5ml by mouth every six hours for pain/terminal restlessness. f. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.5ml by mouth every two hours as needed for anxiety/restlessness. g. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.75ml by mouth every two hours as needed for anxiety/restlessness. h. On 1/8/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml 0.5ml by mouth every six hours for terminal restlessness. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 1/6/19 at 2:00 PM, 1/8/19 at 10:00 AM, 1/10/19 at 8:00 PM, 1/10/19 at 10:00 PM, 1/11/19 at 2:00 AM, and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed on 1/8/19 at 6:00 PM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. Review of the narcotic record log entries with the corresponding Medication Administration Record (MAR) for [MEDICATION NAME] Concentrate 2mg/ml revealed that the medication was documented as signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 1/3/19 at 7:30 PM and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Concentrate 2mg/ml revealed on 1/12/19 at 6:00 AM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. It should be noted that during resident 1's nine day stay at the facility: a. Six doses of [MEDICATION NAME] were signed out in the narcotic log but were not documented as administered in the MAR. b. One dose of [MEDICATION NAME] was documented as administered in the MAR but not signed out of the narcotic log. c. Two doses of [MEDICATION NAME] Concentrate were signed out in the narcotic log but were not documented as administered in the MAR. d. One dose of [MEDICATION NAME] Concentrate was documented as administered in the MAR but not signed out of the narcotic log. 5. Resident 3 was admitted to the facility 9/29/17, he left on 1/11/19 for pacemaker replacement and returned on 1/12/19, with [DIAGNOSES REDACTED]. On 4/30/19 resident 3's medical records were reviewed which revealed the following orders: a. On 7/27/18, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 7.5-325 mg, give 1 tablet by mouth every 6 hours for pain. This order was discontinued 2/1/19. b. On 2/1/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 10-325 mg, give 1 tablet by mouth every 6 hours for pain. c. On 1/3/18, an order was entered into the electronic medication order system for [MEDICATION NAME] HCL Tablet 50 mg, give 1 tablet by mouth every 4 hours as needed for pain. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 7.5-325 mg every 6 hours revealed that on 1/6/19 at 6:00 AM, the medication was documented as administered on the MAR but was not documented as signed out on the narcotic log. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as administered on the MAR but was not documented signed out on the narcotic log for the following dates: 2/26/19 at 6:00 PM, 3/6/19 at 12:00 PM, and 3/10/19 at 6:00 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as signed out of the narcotic log, but was then documented on the MAR as not being administered on the following dates: 3/21/19 at 6:00 AM and 3/29/18 at 6:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed that the medication was documented as signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 9/6/18 at 8:30 PM, 10/4/18 at 9:00 AM, 10/10/18 at 8:00 PM, 10/11/18 at 8:00 PM, 10/16/18 at 8:00 PM, 10/23/18 at 8:00 PM, 10/25/18 at 3:00 AM, 10/25/18 at 9:00 PM, 10/28/18 at 9:30 AM, 11/5/18 at 10:50 AM, 11/7/18 at 8:00 PM, 11/8/18 at 9:00 PM, 11/9/18 at 9:00 PM, 11/14/18 at 8:00 PM, 11/15/18 at 3:00 PM, 11/15/18 at 9:00 PM, 11/19/18 at 3:00 PM, 11/20/18 at 9:00 PM, 11/21/18 at 9:00 PM, 11/28/18 at 9:00 PM, 11/30/18 at 4:00 PM, 12/4/18 at 9:00 PM, 12/5/18 at 9:00 PM, 12/7/18 at 9:00 PM, 12/12/18 at 9:00 PM, 12/13/18 at 9:00 PM, 12/18/18 at 9:20 PM, 12/19/18 at 3:00 AM, 12/19/18 at 8:00 PM, 12/29/18 at 9:50 AM, 1/13/19 at 4:35 PM, 1/15/19 at 9:00 PM, 1/16/19 at 9:00 PM, 1/17/19 at 10:00 PM, 1/23/19 at 9:00 PM, 1/24/19 at 2:30 PM, 1/29/19 at 9:00 PM, 1/30/19 at 8:30 PM, 2/4/19 at 8:55 PM, 2/5/19 at 9:00 PM, 2/7/19 at 10:15 AM, 2/9/19 at 1:45 PM, 2/10/19 at 10:00 AM, 2/12/19 at 8:30 PM, 2/19/19 at 9:00 PM, 2/20/19 at 8:00 PM, 2/21/19 at 10:00 AM, 2/21/19 at 2:00 PM, 2/21/19 at 9:00 PM, 3/1/19 at 1:45 PM, 3/5/19 at 3:15 PM, 3/20/19 at 2:30 PM, 3/21/19 at 9:00 PM, 3/26/19 at 4:00 PM, 3/28/19 at 7:45 PM, 4/2/19 at 10:30 AM, 4/2/19 at 8:30 PM, 4/10/19 at 9:00 PM, 4/11/19 at 9:00 PM, 4/15/19 at 9:15 PM, 4/17/18 at 9:00 PM, 4/18/19 at 9:00 PM, 4/23/19 at 8:00 PM, and 4/29/19 at 8:15 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed the medication was documented as administered on the MAR but was not documented signed out on the narcotic log for the following dates: 12/20/18 at 8:30 PM, 12/25/18 at 2:04 AM, 12/30/18 at 9:50 AM, and 2/8/19 at 1:46 PM. It should be noted that from (MONTH) (YEAR) through (MONTH) 2019, resident 3 had: a. One dose of [MEDICATION NAME] 7.5-325 mg was documented as administered on the MAR but was not documented signed out on the narcotic log. b. Three doses of [MEDICATION NAME] 10-325 mg were documented as administered on the MAR but were not documented signed out on the narcotic log. c. Two doses of [MEDICATION NAME] 10-325 mg were documented signed out of the narcotic log, but were then documented on the MAR as not being administered. d. Fifty-two doses of [MEDICATION NAME] were documented as administered in the narcotic log but not documented as administered in the MAR. e. Four doses of [MEDICATION NAME] were documented as administered in the MAR but were not documented as administered in the narcotic log. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that if a resident asked for narcotic pain medication, the nurse should sign the narcotic out in the Narcotic Log book and document in the MAR that the medication was administered. LPN 1 reported that narcotic medications in the nurses carts were counted at the beginning and end of each shift with the on-coming and off-going nurses to ensure all narcotics were correctly signed out of the Narcotic Log. On 5/1/19 at 3:40 PM an interview was conducted with LPN 3. LPN 3 stated that she had reconciled the narcotic record log in the past. LPN 3 stated she looked at the narcotic sheets for anything strange. LPN 3 stated she looked at the dosage and checked if there were any missing doses. LPN 3 stated I look for anything that is out of the norm. LPN 3 stated that whoever reconciled the narcotic log would sign in the DON spot located at the bottom of the sheet. LPN 3 stated that the narcotic logs were reviewed monthly at the end of the month for any discrepancies. LPN 3 stated that she had never reconciled the narcotic log sheet together with the MAR. On 4/30/19 at 3:29 PM, a interview was conducted with the DON. The DON stated that the process for administering narcotics to a resident was that a resident needed to request a prn medication and then the nurse was to check the MAR for the order and last time it was administered. The DON stated that the nurse was to sign on the MAR and the narcotic record log when a narcotic was administered. The DON stated that the narcotic record and the MAR were to match. The DON stated that there was no process for reconciling the narcotic record sheet and the MAR. The DON stated she did not have additional information regarding the MAR and narcotic record log not matching. |
2020-09-01 |