| 75 |
GUARDIAN ELDER CARE AT WHEELING |
515002 |
20 HOMESTEAD AVENUE |
WHEELING |
WV |
26003 |
2019-08-06 |
755 |
E |
1 |
1 |
WJ7O11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to safely provide pharmaceutical services including administering drugs to meet the needs of resident. The facility failed to utilize only persons authorized by state or local, regulations to administer medication to a resident. A nurse gave medication to a van driver to give to a resident while out of the facility. This is true for one (1) of two (2) complaint/concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: a) Resident #239 Review of complaint concerns found a note written by social services #111 in which Resident #239 stated she did not feel like it was right for the van driver to give her [MEDICATION NAME] (a highly additive medication). A complaint/concern with date of 02/14/19 includes a statement by register nurse (RN) #94 explaining she and the night nurse signed out, the pain mediation, and placed it in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. On 02/15/19 a note by the director nursing (DON) reveals, van driver #63 confirmed he was given medication by nursing staff to give to Resident #239 while out of the facility for a medical appointment. On 02/14/19 risk manager RN #136 documented [MEDICATION NAME] was sent with the van driver #63 and the van driver gave it to the resident at approximately 8:30 AM, and this dose of medication was not on the Medication Administration Record [REDACTED] On 0805/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. b) Incomplete Narcotic Counts On 07/31/19 at 4:31 PM, a review of the Controlled Substance Forms on the 200 hall with Licensed Practical Nurse (LPN) #143 revealed nurses failed to initial the sheets at the change of shift after controlled medications were counted. LPN #143, confirmed medication counts are to be completed between two (2) nurses at the change of shift and both nurses are to initial the forms. Further review at this time found incomplete Controlled Substance Forms on both medication carts on the 200 and 300 hall and the single cart located on the 100 hall. The Assistant Director of Nursing (ADON) acknowledged the Controlled Substance Forms were incomplete during an interview on 07/31/19 at 4:32 PM. Copies of the last six (6) months of the Controlled Substance Forms for all departments were requested at this time. Additional Controlled Substance Forms were received on 08/05/19 at 8:30 AM. Multiple pages were missing and to conserve time the team chose to focus on the past two (2) months. Findings are below: --Wing 100 - lacks nursing signatures on 6/2, 6/3, 6/4, 6/5, 6/7, 6/8, 6/9, 6/12, 6/13, 6/15, 7/22, 7/23, 7/24, 7/26, 7/27, 7/28, 7/29, 7/30, and 7/31. ***No Controlled Substance signature forms were presented for 6/16 - 7/21/19. --Wing 200 - lacks nursing signatures on 7/28, 7/29, 7/30, and 7/31. ***No Controlled Substance signature forms were presented for the period of 05/19/19 through 07/27/19. --Wing 300 - No Controlled Substance signature forms were presented after 05/11/19 --Wing 500 - lacks nursing signatures on 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 7/28, 7/29, 7/30, and 7/31. ***No Controlled Substance signature forms were presented for the period of 06/16/19 through 07/27/19. --Wing 600 - lacks nursing signatures on 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 7/14, 7/15, 7/17, 7/18, 7/19, 7/20, 7/28, and 7/29. ***No Controlled Substance forms were presented for the period of 6/16/19 through 07/13/19. --Wing 700 - lacks nursing signatures on 7/28, and 7/30. ***No Controlled Substance signature forms were presented for the period of 06/01/19 through 07/27/19. --Wing 800 - lacks nursing signatures on 6/4, 6/6, 6/8, 7/28, 7/29, and 7/31. ***No Controlled Substance signature forms were presented for the period of 06/09/19 through 07/27/19. On 08/05/19 at 9:52 AM, a review of the pharmacist's Controlled Substance Audit dated 02/08/19 with the ADON revealed eight (8) missing nursing signatures on the Controlled Substance Forms. The ADON reported staff was educated on this issue. On 08/05/19 at 10:30 AM, the ADON presented a copy of the staff education titled Controlled Substances Accountability. The ADON confirmed the education was completed on 08/01/19, after the survey team identified the incomplete controlled substance forms. |
2020-09-01 |