| 84 |
ST JOHN'S LUTHERAN HOME |
275024 |
3940 RIMROCK RD |
BILLINGS |
MT |
59102 |
2019-03-08 |
755 |
E |
0 |
1 |
SJ2F11 |
**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. Findings include: During an observation and interview on 3/6/19 at 9:15 a.m., an opened 30 ml bottle of liquid [MEDICATION NAME] was in an unlocked refrigerator in the medication room. Staff member N stated, We don't count [MEDICATION NAME] with change of shift narc counts, you can't see it through the bottle. We usually measure what's wasted at the end (when bottle was empty). During an interview with staff members A, B, and C, on 3/6/19 at 12:30 p.m., staff member B stated the facility only locks and counts Schedule II medications. Staff member B handed a sheet of paper with language from regulations (Federal) under the old regulatory system, and stated, The language cross walked to the new regs. Staff member B stated, [MEDICATION NAME] (antianxiety) is a Schedule IV not Schedule II. -Staff member C stated, How are we supposed to measure the [MEDICATION NAME] with the dark bottle, you can't see it? -Staff members A & C both stated, Reconciling is not counting. During an interview on 3/6/19 at 1:00 p.m., staff member Q stated, We have never counted liquid [MEDICATION NAME] before, I think we have even discussed it at our administrative meetings. During an interview on 3/7/19 at 10:00 a.m., staff member C stated the system for monitoring the accuracy for Schedule III-V medications coincided with the date on the medication card, and if the nurse tried to order that medication too soon it would be a red flag (alert) in our system. Staff member C stated, The nurses have to document they gave the medication on the MAR, so we can look at that to see what was administered. If there is a discrepancy we investigate. Staff member C stated if she would need to make a recommendation to administration regarding policy, she would not recommend counting all controlled medications, it would take too much time. During an observation and interview on 3/7/19 at 1:33 p.m., staff member [NAME] demonstrated the current system of keeping track of Schedule III-V medications, as only Schedule II medications are counted each shift. Staff member [NAME] first demonstrated the system for [MEDICATION NAME] scheduled TID. The process included: - There were three cards, each card had originated with 30 tablets, with a corresponding label for morning, noon and evening doses. - For the month of (MONTH) (2019), the medication was started on the 22nd, so that date was circled. - The month of (MONTH) ended on the 28th (due to the number of days in the month), so on (MONTH) 1st the nurse would move down to #1 on the card. - Because there are two left over pills from the 29th and 30th of (MONTH) 2019, staff member [NAME] stated, You would use those pills before starting a new medication card, which would end up being on the 24th of (MONTH) (2019). Staff member [NAME] stated, If I dropped one, I would either go to the 29th or 30th and use one of those pills, or if there were no left over pills, I would go to the start date and one back. Staff member [NAME] said, If a pill was taken from the wrong card, the staff would either replace the pill and tape the back of the card, or go to another card and take a pill from it. Staff member [NAME] stated, I write on the card the date I removed the medication and why. Some (nurses) don't write on the card. For medication that is scheduled PRN, staff member [NAME] stated, You really have no way of knowing if the count is accurate. Staff member [NAME] stated the information passed on, in report, and knowing your resident, would hopefully give you a red flag (alert), but if the medication wasn't used often, you wouldn't recognize a discrepancy timely. Staff member [NAME] stated the on-coming nurse would not know if the total number of tablets was accurate for any of the Schedule III-V medications when they started their shift, because they do not count them. During an interview on 3/7/19 at 1:20 p.m., staff member D stated, If I dropped a pill, I would waste it and get a new one by going backwards one, from the start date. I would verbally pass it on to the next shift. I don't routinely write on the card. During an interview on 3/8/19 at 8:01 a.m., staff member B described the process of accountability for Schedule II medications, and the double check process. When discussing the process of accountability for Schedule III-V medications, staff member B said the pharmacy knew the date the medication was started, and, We circle that on the card. Staff member B stated, If somebody sends that card back too quickly (to pharmacy), the pharmacy would know that. We have great accountability. Staff member B stated if a medication was refused, or needed to be wasted, it would be documented. Staff member B stated, I would have to double check for you, I don't know if wasting is documented on the MAR or somewhere else. I think they write on the back of the bubble pack. Staff member B stated if there were two [MEDICATION NAME] (contracted nurses working) in a row, a discrepancy wouldn't be identified until the next shift when a facility nurse worked. Then, the facility would immediately start an investigation. When asked how the facility would be alerted that PRN medications were missing, staff member B stated, You would discover it when you needed it. It may not be timely. Staff member B stated the facility would have to go back to the MAR and count how many times the medication was given. A review of the facility Medication Pass Procedure, which was not dated, showed, If a medication is dropped or contaminated, mark on bubble pack that it was destroyed/wasted and then take pill from earliest remaining date on the bubble pack to replace current dose . |
2020-09-01 |