cms_WV: 3593
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
3593 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 755 | E | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an adequate system was in place for the tracking and control of controlled substances, which were received, stored at, and administered by the facility. The facility failed to identify the risk of diversion for high abuse medications. This failure had the potential to affect any resident who had controlled substances sent to, stored at, or administered by the facility. Facility Census: 76. Findings included: a) Controlled Medication Count/ Reconciliation During observation of medication administration on 02/25/20 at 8:15 am, Resident #13 was administered [MEDICATION NAME] 0.5 milligrams (mg) from the locked box on the medication cart. Resident #50 was administered [MEDICATION NAME] 5 mg from a locked box in the medication room by Employee #87, a Licensed Practical Nurse (LPN). Employee #87 failed to sign either medication out on the Individual Resident's Controlled Substance Record. Interview of Employee #87, on 02/25/20 at 9:00 am, found the facility has the Individual Resident's Controlled Substance Record in a separate notebook at the nurses' station. A periodical count was performed on these sheets, but no indication the controlled medications were accurately counted on each shift. There is no system to know how many resident's received controlled medications. An interview with the Director of Nursing (DON) on 02/26/20, found the facility was unsure of the exact count of residents receiving controlled medications and no evidence could be located to indicate the nurses did a narcotic count at the beginning and ending of their shifts to determine if a discrepancy/diversion occurred. Immediate action was taken to count the cards of each resident receiving narcotic (controlled) medication and a system to count before and after each shift was put into place. | 2020-09-01 |