| 79 |
GATEWAY TRANSITIONAL CARE CENTER |
135011 |
527 MEMORIAL DRIVE |
POCATELLO |
ID |
83201 |
2018-04-12 |
755 |
D |
1 |
0 |
0IO011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, facility policy review, and staff interviews, it was determined the facility failed to ensure prescription medications were available for administration to 1 of 9 residents (#8) whose medications were reviewed. This failure had the potential to compromise Resident #8's respiratory status and allow exacerbation of her [MEDICAL CONDITION] reflux disease. The facility also failed to ensure medications were secured and locked, including controlled medications. This was true for 8 of 8 bubble pack medication cards left unsecured on the counter at a nurses' station. This failure created the potential for residents, staff, and visitors to access medications not prescribed for them, including controlled medications. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/4/18, documented Resident #8 was cognitively intact and received IV antibiotics. a. Resident #8's physician orders [REDACTED]. * 40 mg [MEDICATION NAME] by mouth for [MEDICAL CONDITION] reflux disease, ordered 2/7/18, * 1 inhalation orally of 18 microgram (mcg) dose of [MEDICATION NAME] every day for asthma, ordered 1/28/18 and discontinued 3/8/18, and * 1 inhalation orally of 100-50 mcg/dose [MEDICATION NAME] every 12 hours for asthma, ordered 1/28/18 and discontinued 3/8/18. Resident #8's (MONTH) (YEAR) MAR indicated [REDACTED] * [MEDICATION NAME] was not administered on 2/9/18 at 8:00 PM and on 2/13/18 and 2/14/18 at 8:00 AM and 8:00 PM. * [MEDICATION NAME] was not administered on 2/26/18 at 7:00 AM. * [MEDICATION NAME] was not administered on 2/26/18 at 7:00 AM. A Progress Note, dated 2/9/18 at 10:34 PM, documented Resident #8's [MEDICATION NAME] was on order from the pharmacy. Two Progress Notes, dated 2/13/18 at 9:54 AM and 9:47 PM, documented Resident #8's [MEDICATION NAME] was ordered from the pharmacy during the morning shift and it had not arrived. The notes documented the physician had not provided further instructions. Two Progress Notes, dated 2/14/18 at 8:09 AM and 9:24 PM, documented the facility was waiting for Resident #8's [MEDICATION NAME] to arrive from pharmacy. The notes documented the physician had not provided further instructions. A Progress Note, dated 2/26/18 at 8:17 AM, documented Resident #8's [MEDICATION NAME] was not found in the medication cart and the pharmacy and physician were notified. A Progress Note, dated 2/26/18 at 8:17 AM, documented Resident #8's [MEDICATION NAME] was not found in the medication cart and the pharmacy and physician were notified. On 4/12/18 at 5:35 PM, the ADON stated she would look into why the medications were not given. The facility did not provide information prior to exit of the survey. b. Inconsistent ordering and delivering of medications: [REDACTED] On 4/12/18 at 2:03 PM, the ADON stated the facility did not have written policy and procedures for ordering and receiving of medications. The ADON stated the process for delivering medications was the pharmacy delivered medications to the A/B nurses' station and the nurses from the other respective nurses' stations were called to collect the medications that belonged in their carts. The ADON stated if time allowed, the A/B nurse delivered the medications to the other nursing stations if the other nurses did not have time to pick them up at the A/B nursing station. The ADON stated if nurses at the other nursing stations did not have time to collect or deliver the medication, then the A/B nurse locked the medications in the A/B drug room until time allowed for delivery or collection. The ADON stated sometimes the pharmacy delivered the medications to the different nursing stations if they had time. On 4/12/18 at 2:20 PM, the ADON and surveyor arrived at the R-Hall nurses' station and observed a stack of eight medication bubble packs including 1 controlled medication sitting unattended on the counter. The ADON obtained the medication packs from the counter and called the nurse over her head-set to the nurses' station. On 4/11/18 at 2:23 PM, LPN #1 arrived at the nurses' station and the ADON handed him the stack of medication bubble packs to store in the medication cart. While the ADON handed the nurse the medication bubble packs she told the nurse not leave the medications unattended. On 4/12/18 at 2:25 PM, the ADON stated the medications should not have been delivered to the R-Hall nurses' station as they were. The ADON stated the nurse who delivered the medications should have hand delivered them directly to the nurse who should have put them in the medication cart. The ADON stated the delivering nurse should not have left the medications on the counter when LPN #1 was not available, as it appears to have happened. The ADON stated the medications should not have been left unattended. On 4/12/18 at 2:33 PM, LPN #1 stated the medications found on the counter included eight bubble packs, including one controlled medication. LPN #1 stated he normally received a phone call when pharmacy delivered medications to the A/B-Hall nurses' station, and he would retrieve the medications. LPN #1 stated he did not receive a phone call 4/12/18 and did not know the medications were delivered to the R-Hall nurses' station. LPN #1 stated the pharmacy did not deliver the medication in a timely manner and some residents missed doses of medications. LPN #1 stated a few months ago it would take 2-3 days for medications to be ordered and delivered to the facility. LPN #1 stated the timeline for deliveries now was 6-7 days after the orders were placed. LPN #1 stated there was not a written process to assist nurses with ordering medications and when to order medications. LPN #1 stated he was unsure why there was a change in the turn around of the medication deliveries from the pharmacy. On 4/12/18 at 6:25 PM, the DNS stated when a medication was low, a couple days left, and needed ordered, there were stickers on the back of the medication bubble pack cards that were faxed to pharmacy. The DNS stated when a nurse noticed a medication beginning to dwindle down they ordered the medication. The DNS said any nurse could order medications and the responsibility was not designated to a specific shift. The DNS stated if a medication was needed immediately, nurses could call the pharmacy for emergent needs. On 4/12/18 at 7:51 PM, the Administrator stated the medication delivery system in place could use improvement. The Administrator was unaware the facility did not have a written policy and procedure for medication ordering and delivery. The pharmacy services policy and procedure was requested from the Administrator at this time. This policy was not provided for review. |
2020-09-01 |