cms_VT: 19
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
19 | MOUNTAIN VIEW CENTER GENESIS HEALTHCARE | 475012 | 9 HAYWOOD AVENUE | RUTLAND | VT | 5701 | 2019-09-23 | 602 | E | 1 | 0 | I8IS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and record review, the facility failed to assure that several residents were free from misappropriation of 28 (twenty-eight) medications as identified by the admission of a Licensed Practical Nurse. Findings include: A concern was raised when there was an investigation conducted by the Attorney General's office in regards to possible drug diversion. The facility conducted audits of all the controlled substance logs and the medical records of the residents that were to receive these type of medications. It was found that on 28 separate occasions, for several different residents in the facility and on various units, a Licensed Practical Nurse (LPN) had not followed the procedure for having a witness to the wasting/destruction of a controlled medication that had been dropped, refused or spit out by a resident and was therefore not administered. These medications included [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME]. During the process of conducting the facility internal investigation, the facility questioned licensed nursing staff regarding the policy for destruction of controlled medications if they are refused or dropped. During the investigation the (LPN) was questioned and his/her answers regarding policies, raised concerns about other nurses that may or may not have been following the policies. The LPN was involved in 28 incidents of wasting medications that were either dropped, refused or spit out, and the LPN was placed on leave until an internal investigation could be completed. When the LPN was informed of his/her termination s/he admitted to taking medications from the residents. During the onsite investigation on 9/23/19, it was confirmed that the facility had written strategy plans and completed multiple corrective actions in response to this incident of 8/9/19. These corrective actions included: termination after suspension, policy revision and education to staff, nursing competencies, audits, initiated a QA (Quality Assurance) project. These corrective actions were completed and will be on-going. Based on corrective actions completed prior to the onsite, this citation is designated as past noncompliance. | 2020-09-01 |