| 55 |
ATHENS HEALTH AND REHABILITATION LLC |
15016 |
611 WEST MARKET STREET |
ATHENS |
AL |
35611 |
2019-08-29 |
602 |
E |
1 |
1 |
39OM11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews and a review of a facility policy titled, Abuse Prevention, the facility failed to ensure resident narcotic medications were not missing. This deficient practice affected RI #87, #48, #222, #223 and #224, five of five residents who were investigated for missing narcotic medication. Findings Include: A review of a facility policy titled Abuse Prevention, with an effective date of [DATE] , revealed: The following are definitions of specific types of abuse: . D) Misappropriation of Resident/ . Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's . belongings or money without the resident's consent . (1) RI #87 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #87's (MONTH) 2019 Medication Administration Record [REDACTED]. [DATE] 6:35 pm, an interview with Employee Identifier (EI) #15, Licensed Practical Nurse(LPN) Charge Nurse was conducted. EI #15 was asked was she familiar with RI #87. EI #15 said yes. EI #15 was asked when she worked on [DATE] did RI #87 complain of pain during her shift. EI #15 said RI #87 sometimes would, he/ she would say his/ her head hurt or he/ she hurt all over. EI #15 was asked when was the last time she had to give RI #87 pain medication. EI #15 said she did not remember, hospice started the medication and she may have given pain medication one time. EI #15 was asked what was the narcotic. EI #15 said it was [MEDICATION NAME]. EI #15 was asked was RI #87 presently on this drug. EI #15 said no, it was stopped. EI #15 was asked what, if any, did RI #87 take for pain since the [MEDICATION NAME] had been stopped. EI #15 said if RI#87 needed pain medication, RI #87 will take a Tylenol. EI #15 was asked how did she know RI #87 was missing pain medication. EI #15 said because she fussed about it everyday, because she had to count that many pills every day; hospice sent a lot of narcotics so on that day she did not have many to count, so when she counted with EI #16 at the start of her shift, she noticed one card was gone. EI #15 was asked what did she say to EI#16. EI #15 said she looked and said to EI #16, RI #87 was missing a card of medication. EI #15 said EI #16 attempted to change the subject, so EI #15 said she went to the nurse and asked her did she sign with EI #16 zeroing the card out. EI #15 said she showed another nurse the paper, that nurse said that was not her signature on the form. EI #15 said she then called EI #2, Assistant Director of Nursing (ADON) and she said to keep EI #16 there and to call the Director Of Nursing (DON). EI #15 said told the ADON she could not keep EI #16 there. EI #15 was asked when she worked, had she known of narcotics being missing before this incident. EI #15 said no, she had not. EI #15 was asked what was the procedure for counting narcotics. EI #15 said the oncoming nurse count with the off going nurse, they call out the resident name, narcotic name and the amount of tablets, then the oncoming nurse will say out loud the number of tablets and both nurse's will look at the narc book, both nurse's sign the sheet; they are not supposed to take the keys until the count is correct. EI #15 was asked how did she know the sheet was wrong. EI #15 said the entire sheet and card was gone; EI #16 took a narcotic log sheet and wrote zero on that sheet. (2) RI #222 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #222's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 10:15 am, the surveyor conducted an interview with EI # 9 LPN. EI #9 was asked when working on [DATE], while counting the narcotic for RI # 222, was there any narcotic medication discrepancy. EI #9 said no. EI #9 was asked how was she made aware of the missing narcotic for RI #222. EI #9 said her DON made her aware and she gave a statement. EI #9 was asked what was the procedure for counting narcotics. EI #9 said the same procedure as they had before and after in the case of RI #224. EI #9 was asked did she have any knowledge of the missing medication for RI #224. EI #9 said no she did not. EI #9 was asked was she aware of any staff members taking residents narcotic medication. EI #9 said no. On [DATE] at 1:55 pm, an interview with EI #7 Registered Nurse (RN). EI #7 was asked was she familiar with RI #223 and RI #222. EI #7 said yes. EI #7 was asked what knowledge did she have on missing narcotics cards for these residents. EI #7 said she worked for three or four days and the cart was full of narcotics then she was off for two days and when she came back, she noticed there was not as many cards, but there had been a lot of discharges and the cards may have been sent with the patients, so she did not think anything about the cards being gone because of the discharges. EI #7 said when she counted with the off going nurse she made her aware of the cards being missing on RI#223 and RI #222. EI #7 was asked who was the nurse. EI #7 said another nurse she was not sure of her last name, she was a RN that worked 3rd shift when ever necessary. EI #7 said after counting they both went to the DON. EI #7 was asked what happened next. EI #7 said they told the DON and gave a statement. EI #7 was asked while on her shift had she given RI #223 or RI #222 pain medication. EI #7 said yes. EI #7 was asked how did she count narcotics on her shift. EI #7 said they have to count the amount of cards and bottles, after that they have to count each individual card, bottle, boxes stating the resident's name, medication name and the amount, then they both sign. EI #7 was asked what was the old way. EI #7 said they count the number of tablets in the card or the amount of liquid narcotic, number of patches. EI #7 was asked how did this differ from the old process to the new process. EI #7 said they count each card, not just the tablet, for example they would count maybe, say 15 cards or five bottles. EI #7 was asked where was this documented. EI #7 said on the narcotic flow sheet found in the front of the book,they documented how many cards or bottles in the cart, each nurse sign this each shift, if they add or take away a card two nurses must sign. EI #7 was asked when she signed with EI #16 to zero out a card, what did she do. EI #7 said she signed. EI #7 was asked when she looked at the card were there any pills on the card. EI #7 said no. EI #7 was asked what was the resident name on the zeroed out card. EI #7 said she did not remember. EI #7 was asked had EI #16 asked her to do this before. EI #7 said she did not recall. EI #7 was asked did she have any knowledge of a staff member taking narcotics from the medication cart for personal use. EI #7 said no. EI #7 was asked did she have any knowledge of this incident. EI #7 said no. On [DATE] at 11:39 am, an interview with EI #13 LPN by phone, was conducted. EI #13 was asked was she familiar with RI # 223 and RI # 222. EI #13 said yes. EI #13 was asked what could she tell the surveyor about the missing narcotic medication. EI #13 said she could not tell the surveyor anything about missing medications. EI #13 was asked how did she count narcotics. EI #13 said before this incident one nurse would have the narcotic book and the other nurse would call out the number of pills on the card. EI #13 was asked how did she count narcotics now. EI #13 said the same way, but in addition they counted the number of cards of narcotic and keep a log both nurse's sign. EI #13 was asked did she have any knowledge of staff taking narcotics from the cart, EI #13 said no. On [DATE] at 6:00 pm, an interview with EI #14/LPN was conducted. EI #14 was asked was she familiar with RI #223 and RI #222. EI #14 said yes. EI #14 was asked when she worked with RI #223 and RI #222 did they ask her for pain medications. EI #14 said they normally asked at bed time. EI #14 was asked when they asked for pain medications did she have pain medication in the cart for these residents. EI #14 said yes. EI #14 was asked when was she made aware of medication, particularly narcotics being missing from the cart. EI #14 said when another nurse went to discharge RI #222 she noticed he/she was missing one card; the nurse asked her to co-sign with her. EI #14 was asked what happened next. EI #14 said the nurse called the DON. EI #14 was asked when RI #222 was discharged did he/she have narcotics to take home. EI #14 said yes. EI #14 was asked who may have taken one of RI #222 cards of narcotics. EI #14 said she did not know. EI #14 was asked when working her shift had any one told her about a staff member taking cards of narcotics. EI #14 said no. EI #14 was asked what was the procedure for counting narcotics. EI #14 said they count each card to make sure the number match the sheet, they match the name with the card, now they count all the cards in the cart to make sure they are in the cart; when narcotics come in they log them onto the narcotic sheet; when they take a card out they subtract from the narcotic sheet. EI #14 was asked how many nurse's must sign the narcotic sheet. EI #14 said two. (3) RI #223 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #223's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 10:15 am, an interview with EI # 9/LPN was conducted. EI # 9 was asked when working on [DATE], while counting narcotics for RI #223, were there any discrepancy with the narcotic count. EI #9 said no. EI #9 was asked how was she made aware of missing narcotic for RI #223. EI #9 said her DON made her aware and she gave a statement. EI #9 was asked what was the procedure for counting narcotics. EI #9 said the same procedure as before and after in the case of RI #224. EI #9 was asked did she have any information on missing narcotics for RI # 223. EI #9 said no she did not. EI #9 was asked was she aware of any staff members taking any resident's narcotic medications. EI #9 said she no. (4) RI # 48 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #48's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 8:25 am, an interview was conducted with EI # 12 LPN. EI #12 was asked what made her aware of RI #48 missing narcotics. EI #12 said because she thought she remembered seeing three cards and she noticed there was only two cards. EI #12 said she could not remember signing in three cards for RI #48 or if another nurse signed them in and she co-signed. EI #12 was asked what did she do next. EI #12 said the next morning she asked the day shift nurse if she removed a card of narcotics on RI #48. EI #2 said the nurse told her she had turned one card in to the DON. EI #12 said she asked the DON where was the paper that they had to sign, who ever takes the paper to the DON, they both have to sign; the nurse and the DON both have to sign when it is for destruction. EI #12 was asked what happened next. EI #12 said the DON started trying to tell her why they had to get the card out, the DON was telling her something about a new script. EI #12 said when she left EI #10 was looking for the paper. EI #12 was asked what happened next. EI #12 said she was still looking for the sheet and she said she would get the DON to sign the sheet. EI #12 said when she got home EI #10 called her and said EI #12 was right, that was not the card that was turned in, the prescription number did not match, the one that they destroyed. EI #12 said she kept saying she did not understand because all three cards came in together, so if one was expired all three would have been expired; EI # 10 kept saying no. EI #12 was asked why would EI #10 say no they had destroyed the drug. EI #12 said she believed EI #10 had it mixed up with some other drug. EI #12 said to EI #10 she and the DON need to find the sheets, but she did call and say that there was one card missing. EI #12 said she came back in the next night and she was told the DON had taken care of it. EI #12 was asked did she have any knowledge of any staff member taking the resident's narcotic. EI #12 said no. EI #12 was asked what was the procedure for counting narcotic. EI #12 said the old way was the oncoming nurse would be in the cart and the off going nurse would have the book calling out the resident name, drug name and how many. EI #12 was asked what was the new process. EI #12 said before they count the pills, the off going nurse will tell the oncoming nurse the total number of cards in the cart and then they will count, the oncoming will be counting in the cart and the offgoing nurse would be in the book calling out the resident name, drug name and number of tablets. EI #12 was asked did she have any other information to offer. EI #12 said no. EI #12 was asked who did she count off with on [DATE]. EI #12 said she thought it was EI #11. (5) RI #224 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI # 224 (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 9:45 am, an interview with EI # 9/ LPN was conducted. EI #9 was asked where was she working on [DATE] from ,[DATE] am. EI #9 said 1st East Hall. EI #9 was asked when she worked with RI #224 did she administer pain medications. EI #9 said no she did not. EI #9 was asked when she worked with RI #224 did she/ he complain of pain. EI #9 no. EI #9 was asked when her shift ended who did you count with. EI #9 said she counted with EI #3, she was the unit manager and was working that weekend she counted with her. EI #9 was asked what was the procedure for counting narcotics. EI #9 said the procedure then was she would stand at the book, oncoming nurse would stand at the narcotic drawer, she would call out the resident name, medication and number of tablets, the oncoming would verify what was on the card to what EI #9 called out and the oncoming would look at the book also to verify what EI #9 had called out. EI #9 was asked when she counted off on [DATE] were there any discrepancy with the medication narcotic count on this date. EI #9 said no. EI #9 was asked what was the new procedure for counting narcotics at the end of her shift. EI #9 said at the beginning and end of every shift they have a form that the oncoming and offgoing nurse will sign and it has to list how many cards are in the narcotic drawer, this included liquid bottle narcotic, narcotic patches, everything was accounted, for example if there was 23 narcotic in the drawer both nurse's sign and write 23, if a card was empty, there was a place to write the resident name, prescription number, name of the medication and both nurse's sign; there was a ledger that will say R-removed, D-destruction, the same procedure was used for receiving a medication to the cart, list resident name, medication name and prescription number. EI #9 was asked how was she made aware of the missing medications for RI #224. EI #9 said her DON called her in to give a statement. EI #9 was asked did she have any knowledge of the missing medications for RI #224. EI #9 said no she did not. On [DATE] at 12:09 pm, an interview was conducted with EI # 10/LPN Charge Nurse, by phone. EI #10 was asked when working with RI #224 did she administer pain medications. EI #10 said no. EI #10 was asked did RI #224 ask for pain medications during the day time. EI #10 said RI #224 took it at night to help rest. EI #10 said she thought she gave it a few times, here or there. EI #10 was asked when she worked with RI #224 did the resident complain of pain. EI #10 said the resident would sometimes and she offered the resident medication but RI #224 would decline, saying it would make him/ her drowsy, so he/ she would wait until night, due to therapy during the day. EI #10 was asked when her shift ended did she count with the oncoming nurse. EI #10 said yes, she counted at every shift change. EI #10 was asked what was the procedure for counting narcotics. EI #10 said there had to be two nurse's, oncoming and offgoing, the patient's name, medication name and number of pills. EI #10 was asked were the two nurse's required to sign. EI #10 said yes, the narcotic record sheet, both nurse's would sign that the count are correct and accounted for. EI #10 was asked when she counted at the end of her shift had she found any discrepancies with the narcotic count. EI #10 said no and if she had she would called the DON. EI #10 was asked was she aware of any missing medications. EI #10 said she was aware of RI #224 having missing medications and this had been reported. EI #10 was asked did she have any other knowledge of missing medication. EI #10 said she know medications were missing, it was reported, investigated and that nurse was reported to the Board of Nursing and the police was involved. EI #10 was asked was she aware of any nurse taking medications. EI #10 said she was not aware of this until the incident had occurred and being reported, she never suspected any nurse's of taking medications. On [DATE] at 4:54 pm, interview with EI #11/RN Charge Nurse. EI #11 was asked was she familiar with RI #48, RI #223 and RI # 224. EI #11 said she was familiar with RI #48. EI #11 was asked what could she tell the surveyor about missing narcotics on RI #48. EI #11 said she could not recall what happened but could remember RI #224. EI #11 was asked what happened with RI #224. EI #11 said it was a Sunday, she was not sure this was the day, she came to work, and EI #16 was working there; and EI #16 went to count, EI #11 counted all the narcotic and took the keys, it was in the evening. EI #11 said the resident asked for pain pills,so she went to the cart, opened the narcotic box and she figured out there was one more card that should have had some pills on it but it was not there, so she had to use a new card, she did not remember if some was used from the new card, she did remember, she had to use from a new card. EI #11 said the day shift nurse usually would remove the card and take it to the office, if the card was expired, but she was still thinking the card was not empty. She said she talked to EI #10 the next day and EI #10 agreed there should have been some left, on the same day EI #16 was working on the other hall, so EI #10 and herself called over to talk EI #16. EI #11 was asked what happened next. EI #11 said she and EI #10 asked EI #16 about RI #224 saying there was two cards. EI #11 was asked what did EI #16 say. EI #11 said, EI #16 said she emptied one card. EI #11 was asked what did she or EI #10 say. EI #11 said they asked her where was the sheet with two nurse's signing. EI #11 was asked what did EI #16 say. EI #11 said EI #16 said she put it on the top of the door rack to the med room, then she said she may have laid it on the desk. EI #11 was asked what did she say. EI #11 said they said okay, they searched and could not find it. EI #11 was asked what did she do next. EI #11 said EI #10 reported to the DON. EI #10 said she did not remove the card, she was sure then it was another card of medication. EI #11 was asked what was the procedure for counting narcotics during shift change. EI #11 said two nurse's have to count with the resident name, dosage, milligrams, drug name quantity and they both sign. EI #11 was asked what was the new procedure. EI #11 said they count the number of cards each resident have, when they remove the card two nurses write the resident name, drug name and both nurses sign it; when they receive the card both nurses will sign so every one will know what came in or went out. EI #11 was asked did she know of any staff member that have taken the resident medications particularly the narcotic. EI #11 said no except for this incident. EI #11 was asked what made her suspect EI #16 as being the person to remove the narcotic from the cart. EI #11 said because every hall EI #16 had worked something had been missing and EI #16 was changing her story. EI #11 said they never had this problem on their hall since she started working there. EI #11 was asked when did she think or hear of issues with narcotics being missing on other halls. EI #11 said it was when they looked at their cart, EI #10 and herself, then they started talking among themselves and they made night shift aware and they also said they noted issues on other halls. EI #11 was asked who on the night shift said they noticed missing medications. EI #11 said she did not remember, they did not have these types of issues on their hall since she started working there, until this happened. On [DATE] at 5:50 pm, an interview with EI #3/RN Unit Manager/Rehab was conducted. EI #3 was asked was she familiar with RI #224. EI #3 said she could not remember. EI #3 was asked was she familiar with RI #48. EI #3 said she was. EI #3 was asked what could she tell the surveyor about these resident missing narcotics. EI #3 said she just remembered seeing a card with 11 or 12 tablets on RI #224, from the backup pharmacy. EI #3 was asked what made her remember 11 or 12 tablets on RI #224. EI #3 said because the tablets were from back-up pharmacy. EI #3 was asked who did she count with on [DATE]. EI #3 said she would have counted off with EI #11. EI #3 was asked how many cards of narcotic did RI #224 have. EI #3 said she didn't recall .EI #3 was asked what was the procedure for counting narcotics at the end of the shift. EI #3 said the oncoming and off going nurse's would count the cards, bottles and they write down the total number and sign, then the oncoming nurse count the actual narcotic as the off going nurse called out the resident name, drug name, number of tabs and they must match, then both nurse's signed the control log sheet. EI #3 was asked where were these sheets kept. EI# 3 said in the front of the narcotic book. EI #3 was asked did she have any knowledge of the staff taking the resident's narcotics. EI #3 said she did not have any knowledge personally. The Alabama Department of Public Health Online Incident Reporting System received facility reports regarding the misappropriation of resident property on [DATE], [DATE] and [DATE]. As a result of these facility reports an onsite visit was conducted, in conjunction with the recertification survey. This deficiency is cited as a result of the investigations of complaint/report #AL 378, #AL 303 and #AL 296. |
2020-09-01 |