cms_UT: 79
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 79 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2019-05-01 | 755 | E | 1 | 0 | OCVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined, for 5 of 5 sample residents, that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail and enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, nursing staff had telephone orders signed by the physician that were available to fill in for scheduled 2 medications. In addition, residents narcotic record log did not match the Medication Administration Records (MAR) for narcotic administration. Resident identifiers: 1, 2, 3, 4 and 5. Findings include: 1. On 4/30/19 at 1:00 PM, an observation was made with Registered Nurse (RN) 1 of her medication cart narcotic drawer. There were 5 telephone orders that were signed by the MD with his Drug Enforcement Administration (DEA) number written on them. The telephone orders did not have a date, resident name, medication or dosing instructions. The telephone orders were stamped with V.O.R.B. (verbal order read back). 2. Resident 2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 5/1/19. Resident 2's physicians orders revealed the following: a. On 3/7/19, [MEDICATION NAME] immediate 5mg (milligrams) tablet (1) tab (tablet) po (oral) Q (every) 4h (hours) prn (as needed) pain (times) 30. The telephone order had Licensed Practical Nurse (LPN) 1's signature. There was a stamp V.O.R.B. with the Medical Director's (MD) signature and the MD's DEA number. b. On 3/18/19, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tab. Give 1 tab po Q4 hours prn pain. The telephone order had to dispense 60 tablets with no refills. The telephone order had a nurses signature with V.O.R.B stamped above it and the physicians signature with the DEA number. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] immediate 5 mg every 4 hours as needed revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/6/19 at 12:30 AM, 3/7/19 at 8:00 PM, 3/8/19 at 5:00 AM and 3/12/19 at 6:30 AM. It should be noted that 4 doses were signed out on the narcotic record log and were not signed out as administered on the MAR. The (MONTH) 2019 MAR revealed on 3/9/19 at 1:25 AM that [MEDICATION NAME] was administered but the narcotic record log did not have the medication signed out. In addition, the MAR revealed that [MEDICATION NAME] 5 mg was administered on 3/27 at 4:27 PM and 3/31/19 at 5:59 PM. There was no corresponding narcotic record log available for the 2 doses. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] table 5-325 mg every 4 hours as need revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/14/19 at 10:30 PM, 3/15/19 at 2:30 AM, 3/20/19 at 6:00 AM, 3/20/19 at 9:00 AM, 3/22/19 at 6:00 AM, 3/23/19 at 11:00 PM, 3/25/19 at 6:00 AM, 3/26/19 at 3:00 PM, 3/26/19 at 7:00 PM, 3/27/19 at 4:50 PM, 3/28/19 at 3:00 AM, 3/31/19 at 6:00 PM, 3/31/19 at 10:00 PM, 4/3/19 at 5:00 AM, 4/4/19 at 2:40 AM, 4/4/19 at 9:30 PM, 4/5/19 at 5:00 PM, and 4/5/19 at 7:30 AM. It should be noted that 17 doses were signed out on the narcotic record log and were not signed out as administered on the MAR. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] tablet 5-325 mg every 4 hours as needed revealed the following: a. On 3/30/19, the MAR revealed that the [MEDICATION NAME] was administered three times that day at 1:59 AM, at 1:38 PM and at 6:37 PM. The narcotic record revealed [MEDICATION NAME] was pulled medication supply and administered at 12:30 AM, no time was documented, at 1:30 PM and at 6:30 PM. b. On 4/5/19, the MAR revealed that the [MEDICATION NAME] was signed as administered three times that day at 8:40 AM, at 1:55 PM, and at 7:44 PM. The narcotic record revealed [MEDICATION NAME] was pulled at 5:00 AM, at 7:30 AM, at 1:40 PM and at 7:45 PM. On 5/1/19 at 3:15 PM, an interview was conducted with LPN 1. LPN 1 stated that the Medical Director (MD) provided signed telephone order with his DEA number that were not filled in with the resident name, medication or dosing instructions. LPN 1 stated that the telephone order dated 3/7/19 for [MEDICATION NAME] had been signed by the MD prior to 3/7/19. LPN 1 stated that she filled in the order section on 3/7/19 and sent the telephone order to the pharmacy. LPN 1 stated that she called the MD to obtain a verbal order for the medication. 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 5/1/19. Resident 4's telephone orders revealed the following: a. On 1/25/19 at 4:35 PM, a verbal order for [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 MG give 1 tablet by mouth every 4 hours as needed for pain related to Generalized abdominal pain. The physician signed the order on 1/30/19 at 5:06 PM. There was no script in the medical record. The order was discontinued on 3/4/19. b. On 2/15/19, [MEDICATION NAME] 10/325 1 tab po Q4H PRN. The order was to dispense 120 with no refills. The MD signed with the DEA number on the telephone order. There was no nurses signature. V.O.R.B was stamped on the telephone order. c. On 3/22/19, [MEDICATION NAME] tablet 10-325 M[NAME] Give 1 tablet Q 4 hours prn, NTE (not to exceed) 300 mg in 24 hr. Give 1 tablet po q 4 hours. NTE 3000mg in 24 hours. The order was to dispense 120 tablets with 3 refills. The telephone order had the MD signature and his DEA number. RN 1's signature with V.O.R.B was on the telephone order. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 10/325 mg revealed that the medication was documented as signed out on the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 2/23/19 at 7:25 AM, 3/9/19 at 10:30 AM, 4/7/19 at 12:00 PM, 4/11/19 at 9:00 PM, 4/12/19 at 9:00 PM, 4/14/19 at 1:20 PM, 4/15/19 at 9:55 PM, 4/18/19 at 9:00 PM, 4/26/19 at 6:45 PM and 4/28/19 at 9:00 PM. It should be noted that 10 doses were documented as administered in the narcotic log but not documented as administered in the MAR. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 10/325 mg revealed the following: a. On 2/4/19 at 12:10 PM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 was administered and there was no record of the medication being administered according to the narcotic record log. b. On 2/22/19 at 11:33 AM, the MAR revealed that [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered and there was no record of the medication being administered according to the narcotic record log. c. On 3/21/19 at 6:00 AM, the MAR revealed that the nurse did not sign in the MAR that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was administered. The narcotic record log revealed that on 3/20/19 at 5:30 AM and 3/20/19 at 6:00 AM the medication was administered. d. 3/29/19 at 6:00 AM, the MAR revealed that the nurse did not sign that the [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg as being administered. The narcotic record log revealed that on 3/29/19 at 6:00 AM the [MEDICATION NAME] was administered. On 5/1/19 at 3:00 PM, an interview was conducted with LPN 2. LPN 2 stated that the MD provided the nurses signed telephone orders that did not have the residents name, medication or dispensing instruction. LPN 2 stated that she called the MD prior to filling in name, medication and dispensing instruction on the telephone orders. LPN 2 stated that she did not sign the telephone orders. LPN 2 confirmed that she wrote the telephone order on 2/15/19 for the [MEDICATION NAME] 10/325. LPN 2 stated that on 2/15/19 she used a telephone order that the MD had signed and not filled in. 4. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/1/19 resident 5's medical records were reviewed. Review of resident 5's physician orders [REDACTED]. a. On 10/3/18, a telephone order for [MEDICATION NAME] Extended Release (ER) 10 milligrams by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. b. On 10/14/18, a telephone order for [MEDICATION NAME] (HCL) with Tylenol (APAP) 10/325 mg tablet, take 1 tablet by mouth every 6 hours as needed for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. c. On 10/25/18, an order for [REDACTED]. The amount of medication ordered dispensed was 60 tablets. d. On 11/11/18, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. e. On 12/3/18, a telephone order for [MEDICATION NAME] HCL ER 10 mg 1 tablet by mouth two times a day was written. The amount of medication ordered dispensed was 60 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. f. On 1/29/19, a telephone order for [MEDICATION NAME] 10/325 mg 1 tablet by mouth every 6 hours as needed was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but was stamped V.O.R.B. g. On 3/7/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. h. On 4/17/19, a telephone order for [MEDICATION NAME] Reformulated 10 mg tablet ER 1 tablet by mouth two times a day for pain was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by Registered Nurse (RN) 1. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL APAP 10/325 mg every 6 hours as needed revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates; 8/29/18 at 9:00 PM, 9/7/18 at 1:00 AM, 9/12/18 at 4:00 AM, 9/13/18 at 2:00 AM, 10/3/18 at 2:00 AM, 10/12/18 at 1:00 AM, 11/13/18 (day not documented clearly but located between 11/9/18 and 11/22/18) at 1:00 AM, 11/26/18 at 9:50 AM, 11/28/18 at 10:00 AM, 11/29/18 at 4:00 PM, 12/1/18 at 10:10 AM, 12/2/18 at 10:30 AM, 12/18/18 at 5:00 AM, 12/29/18 at 11:59 PM, 1/22/19 at 7:00 AM, 2/1/19 at 5:00 AM, 2/15/19 at 3:00 AM, 2/15/19 at 11:30 PM, 2/17/19 at 1:20 AM, 3/16/19 at 6:00 AM, 3/21/19 at 11:00 PM, 3/31/19 at 3:00 PM, 4/12/19 at 6:20 AM, 4/20/19 at 12:45 AM, 4/25/19 at 1:00 AM, 4/25/19 at 11:30 PM, and 4/30/19 at 11:00 PM. It should be noted that 27 doses were documented as administered in the narcotic record log but not documented as administered in the MAR. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Reformulated 10 mg tablet ER by mouth twice daily revealed the following: a. On 11/8/18 at 10:00 AM, the medication was documented as refused and wasted. The narcotic log contained only one nurse signature for the wasted medication. b. The medication was documented as signed out on the narcotic record log on 2/2/19 at 9:30 PM and then again at 9:45 PM. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. c. The medication was documented as signed out in the narcotic log on 2/9/19 at 11:30 PM twice. The two scheduled doses were removed from the narcotic count for the one scheduled administration time. d. On 4/13/19 at 19-23 (7:00 PM to 11:00 PM), there was a code documented which was to HOLD the medication and see progress notes. Review of the progress notes revealed no documentation for this medication. The medication was documented as signed out in the narcotic log and was deducted from the medication count. On 5/1/19 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 5 often refused her pain medications. The DON stated that if the resident refused the medication that the nursing staff should be documenting that in a progress note. The DON further stated that if the medication was pulled prior to the resident refusing then the nursing staff should be wasting the medication. The DON stated that the narcotic log should have two licensed nursing staff signatures when a narcotic was wasted. The DON stated that the documentation in the Narcotic Record log and the MAR should match. On 5/1/19 at 3:40 PM, an interview was conducted with LPN 3. LPN 3 stated that the pharmacy delivered two times a day except for Sunday afternoon. LPN 3 stated that narcotics were delivered in a different colored bag. LPN 3 stated that if a resident ran out of a narcotic pain medication that the nursing staff could write the prescription with the signed script provided by the MD. LPN 3 stated that nursing staff then call the MD to inform him of the new order. LPN 3 stated that she did not document that she called and notified the MD of the narcotic order that was written. LPN 3 stated that the nursing staff filled out paperwork because they were agents' of the MD. LPN 3 stated that an agent meant that they could write prescriptions on behalf of the MD. LPN 3 stated that as an agent the staff could only write for a refill of an existing order or a verbal order to write a new prescription. LPN 3 stated that the MD had provided the facility nursing staff with pre-signed blank telephone orders, and that she had used these to write prescriptions for narcotic pain medications in the past. LPN 3 stated that she was not aware any exclusions for being an agent and writing medication orders. LPN 3 again stated that she could write a prescription for narcotic pain medications. LPN 3 stated she could write for Scheduled II narcotics. LPN 3 stated that [MEDICATION NAME] was a Scheduled II and that Oxy was a Scheduled III and she could write a prescription for both of them. LPN 3 stated that she had written prescriptions for [MEDICATION NAME] and [MEDICATION NAME] as an agent for the MD. LPN 3 stated she had never written a prescription for [MEDICATION NAME] or [MEDICATION NAME]. LPN 3 stated that she had reconciled the narcotic log in the past. LPN 3 stated she looked at the narcotic sheets for anything strange. LPN 3 stated she looked at the dosage and checked if there were any missing doses. LPN 3 stated she would look at nursing notes or the MAR to see why a medication was not administered. LPN 3 stated I look for anything that is out of the norm. LPN 3 stated that whoever reconciled the narcotic log would sign in the DON spot located at the bottom of the sheet. LPN 3 stated that the narcotic logs were reviewed monthly at the end of the month for any discrepancies. LPN 3 stated that she had never reconciled the narcotic record log together with the MAR. On 5/1/19 at 4:01 PM, a follow-up interview was conducted with the DON. The DON stated that when she reconciled the narcotic logs she looked for the correct count and that the dose documented as given matched up. That the count is accurate. The DON stated that she did not compare the narcotic record log to the MAR. The DON stated they were not capturing or identifying discrepancies between the MAR and narcotic record log. The DON was asked how she identified or monitored to ensure that nursing staff were not diverting narcotics. The DON stated she made sure all the medication cards match, but not from MAR to narcotic sheet. 5. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was admitted to hospice on 1/3/19 for end of life cares, and passed away on 1/12/19. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that when a resident was on hospice, all of the resident's medications were provided by the hospice company. LPN 1 stated that the facility created a narcotic record log to track all hospice provided narcotics. On 4/30/19 resident 1's medical records were reviewed. Review of resident 1's physician orders [REDACTED]. a. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml (milliliters) 1ml by mouth every hour as needed for pain/shortness of breath. b. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.25ml by mouth every hour as needed for pain/shortness of breath. c. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.5ml by mouth every hour as needed for pain/shortness of breath. d. On 1/3/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 100mg/5ml 0.75ml by mouth every hour as needed for pain/shortness of breath. e. On 1/8/19, an order was entered into the electronic medication order system for [MEDICATION NAME] 20mg/ml 0.5ml by mouth every six hours for pain/terminal restlessness. f. On 1/3/19 an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.5ml by mouth every two hours as needed for anxiety/restlessness. g. On 1/3/19 an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml give 0.75ml by mouth every two hours as needed for anxiety/restlessness. h. On 1/8/19 an order was entered into the electronic medication order system for [MEDICATION NAME] Concentrate 2mg/ml 0.5ml by mouth every six hours for terminal restlessness. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed that the medication was documented as signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 1/6/19 at 2:00 PM, 1/8/19 at 10:00 AM, 1/10/19 at 8:00 PM, 1/10/19 at 10:00 PM, 1/11/19 at 2:00 AM, and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] 100mg/5ml revealed on 1/8/19 at 6:00 PM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Concentrate 2mg/ml revealed that the medication was documented as signed out of the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates: 1/3/19 at 7:30 PM and 1/11/19 at 4:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Concentrate 2mg/ml revealed on 1/12/19 at 6:00 AM the medication was documented on the MAR as administered but was not documented as signed out on the narcotic log. It should be noted that during resident 1's nine day stay at the facility: a. Six doses of [MEDICATION NAME] were signed out in the narcotic log but were not documented as administered on the MAR. b. One dose of [MEDICATION NAME] was documented as administered in the MAR but not signed out of the narcotic log. c. Two doses of [MEDICATION NAME] Concentrate were signed out in the narcotic log but were not documented as administered on the MAR. d. One dose of [MEDICATION NAME] Concentrate was documented as administered in the MAR but not signed out on the narcotic record log. 6. Resident 3 was admitted to the facility 9/29/17, discharged on [DATE] for pacemaker replacement and returned on 1/12/19, with [DIAGNOSES REDACTED]. On 4/30/19 resident 3's medical record was reviewed. Resident 3's active physician's orders [REDACTED].> a. On 7/27/18, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 7.5-325 mg, give 1 tablet by mouth every 6 hours for pain. This order was discontinued 2/1/19. b. On 2/1/19, an order was entered into the electronic medication order system for [MEDICATION NAME] Tablet 10-325 mg, give 1 tablet by mouth every 6 hours for pain. c. On 1/3/18, an order was entered into the electronic medication order system for [MEDICATION NAME] HCL Tablet 50 mg, give 1 tablet by mouth every 4 hours as needed for pain. Resident 5's signed physician orders [REDACTED]. a. On 9/8/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by RN 1 and contained a V.O.R.B. (verbal order read back) stamp. b. On 9/23/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by RN 1 and contained a V.O.R.B. stamp. c. On 10/7/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 180 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. d. On 11/8/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 4 and contained a V.O.R.B. stamp. e. On 11/24/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. f. On 1/7/19, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by RN 2 and contained a V.O.R.B. stamp. g. On 12/22/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by RN 1 and contained a V.O.R.B. stamp. h. On 12/31/18, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by RN 1 and contained a V.O.R.B. stamp. i. On 1/25/19, a telephone order for [MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order was signed by LPN 5 and contained a V.O.R.B. stamp. j. On 2/1/19, a telephone order for [MEDICATION NAME] Tablet 10-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. k. On 2/28/19, a telephone order for [MEDICATION NAME] Tablet 10-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. l. On 4/1/19, a telephone order for [MEDICATION NAME] Tablet 10-325 mg by mouth every 6 hours was written. The amount of medication ordered dispensed was 120 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. m. On 9/29/18, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 90 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. n. On 11/23/18, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 180 tablets. The order did not contain a nurses signature, but instead was stamped with V.O.R.B. o. On 1/25/19, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by LPN 1 and contained a V.O.R.B. stamp. p. On 4/27/19, a telephone order for [MEDICATION NAME] HCL Tablet 50 mg by mouth every 4 hours as needed was written. The amount of medication ordered dispensed was 60 tablets. The order was signed by LPN 5 and contained a V.O.R.B. stamp. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 7.5-325 mg every 6 hours revealed that on 1/6/19 at 6:00 AM, the medication was documented as administered on the MAR but was not documented as signed out on the narcotic record log. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as administered on the MAR but was not documented as signed out on the narcotic record log for the following dates: 2/26/19 at 6:00 PM, 3/6/19 at 12:00 PM, and 3/10/19 at 6:00 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] Tablet 10-325 mg every 6 hours revealed that the medication was documented as signed out of the narcotic log, but was then documented on the MAR as not being administered on the following dates: 3/21/19 at 6:00 AM and 3/29/18 at 6:00 AM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed that the medication was documented signed out of the narcotic log, but the medication was not documented on the MAR as being administered on the following dates: 9/6/18 at 8:30 PM, 10/4/18 at 9:00 AM, 10/10/18 at 8:00 PM, 10/11/18 at 8:00 PM, 10/16/18 at 8:00 PM, 10/23/18 at 8:00 PM, 10/25/18 at 3:00 AM, 10/25/18 at 9:00 PM, 10/28/18 at 9:30 AM, 11/5/18 at 10:50 AM, 11/7/18 at 8:00 PM, 11/8/18 at 9:00 PM, 11/9/18 at 9:00 PM, 11/14/18 at 8:00 PM, 11/15/18 at 3:00 PM, 11/15/18 at 9:00 PM, 11/19/18 at 3:00 PM, 11/20/18 at 9:00 PM, 11/21/18 at 9:00 PM, 11/28/18 at 9:00 PM, 11/30/18 at 4:00 PM, 12/4/18 at 9:00 PM, 12/5/18 at 9:00 PM, 12/7/18 at 9:00 PM, 12/12/18 at 9:00 PM, 12/13/18 at 9:00 PM, 12/18/18 at 9:20 PM, 12/19/18 at 3:00 AM, 12/19/18 at 8:00 PM, 12/29/18 at 9:50 AM, 1/13/19 at 4:35 PM, 1/15/19 at 9:00 PM, 1/16/19 at 9:00 PM, 1/17/19 at 10:00 PM, 1/23/19 at 9:00 PM, 1/24/19 at 2:30 PM, 1/29/19 at 9:00 PM, 1/30/19 at 8:30 PM, 2/4/19 at 8:55 PM, 2/5/19 at 9:00 PM, 2/7/19 at 10:15 AM, 2/9/19 at 1:45 PM, 2/10/19 at 10:00 AM, 2/12/19 at 8:30 PM, 2/19/19 at 9:00 PM, 2/20/19 at 8:00 PM, 2/21/19 at 10:00 AM, 2/21/19 at 2:00 PM, 2/21/19 at 9:00 PM, 3/1/19 at 1:45 PM, 3/5/19 at 3:15 PM, 3/20/19 at 2:30 PM, 3/21/19 at 9:00 PM, 3/26/19 at 4:00 PM, 3/28/19 at 7:45 PM, 4/2/19 at 10:30 AM, 4/2/19 at 8:30 PM, 4/10/19 at 9:00 PM, 4/11/19 at 9:00 PM, 4/15/19 at 9:15 PM, 4/17/18 at 9:00 PM, 4/18/19 at 9:00 PM, 4/23/19 at 8:00 PM, and 4/29/19 at 8:15 PM. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] HCL Tablet 50 mg every 4 hours as needed revealed the medication was documented as administered on the MAR but was not documented as signed out on the narcotic record log for the following dates: 12/20/18 at 8:30 PM, 12/25/18 at 2:04 AM, 12/30/18 at 9:50 AM, and 2/8/19 at 1:46 PM. It should be noted that from (MONTH) (YEAR) through (MONTH) 2019, resident 3 had: a. One dose of [MEDICATION NAME] 7.5-325 mg was documented as administered on the MAR but was not documented as signed out on the narcotic log. b. Three doses of [MEDICATION NAME] 10-325 mg were documented as administered on the MAR but were not documented as signed out on the narcotic log. c. Two doses of [MEDICATION NAME] 10-325 mg were documented as signed out of the narcotic log, but were then documented on the MAR as not being administered. d. Fifty-two doses of [MEDICATION NAME] were documented as administered in the narcotic log but not documented as administered on the MAR. e. Four doses of [MEDICATION NAME] were documented as administered on the MAR but were not documented as administered in the narcotic log. On 4/30/19 at 12:12 PM, an interview was conducted with LPN 1. LPN 1 stated that if a resident asked for narcotic pain medication, the nurse signed the narcotic record log and document on the MAR that the medication was administered. LPN 1 stated that if the resident did not have an order for [REDACTED]. LPN 1 stated that the facility MD had all of the nurses listed as agents which meant that the nurses were able to write scripts for the facility MD. LPN 1 stated that the MD kept a stack of blank signed scripts at the facility, and that those were kept in the medication cart's narcotic drawers to be filled out as needed. LPN 1 stated that after she filled out the script she would then fax it to the pharmacy. LPN 1 stated that the pharmacy only delivered medications once or twice a day, so after faxing the script LPN 1 would then call the pharmacy for the combination code to the lock, to access the emergency kit in order to administer the narcotic to the resident as quickly as possible. LPN 1 stated that that the pharmacy would only give the combination code to the nurse after receiving the fax with the signed script. LPN 1 reported that narcotic medications in the nurses carts were counted at the beginning and end of each shift with the on-coming and off-going nurses to ensure all narcotics were correctly signed out of the Narcotic Log. On 4/30/19 at 1:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facilities process to obtain narcotics was to have the MD write a script and send it to the pharmacy for narcotics. The DON stated that if there were no refills for the narcotic medications then the MD would have to fill out another script and fax it to the pharmacy. On 4/30/19 at 3:29 PM, a follow up interview was conducted with the DON. The DON stated that the process for administering narcotics to a resident was that a resident needed to request a prn medication and then the nurse was to check the MAR for the order and the time it was last administered. The DON stated that the nurse was to sign on the MAR and the narcotic record log when a narcotic was administered. The DON stated that the narcotic record and the MAR were to match. The DON stated that the facility did not have a reconciliation process for narcotics. The DON stated that the nurses completed a count at every shift change. The DON stated that the Count was when both nurses compared the narcotic record sheet and the actual number of pills in the narcotic drawer. The DON stated that there was no process for reconciling the narcotics, the narcotic record log and the MAR. The DON stated that the MD had given approval for all the nurses to be Agents. The DON stated that an agent was able to fill in a signed script for narcotics with the MD's verbal permission. The DON stated that nurses were able to fill in the presigned scripts for scheduled 2 medications. The DON provided a copy of the agent contract. A form titled Designating Agent of Practitioner For Communicating Controlled Substance Pres | 2020-09-01 |