Observations
Based on a review of client records, the facility failed to ensure that each client had a completed medication administration record in their file in five of five client records reviewed.
The findings include:
Five closed client records which required documentation of medication administration were reviewed on February 7, 2014. The facility failed to document whether or not all medications were administered and/or if the client refused medications on the medication administration records in client records # 1, 2, 5, 7, and 9. Additionally, the facility had to search through several different filing cabinets to produce all of the requested medication administration records for the closed client records as there were medication administration logs that were not in the closed client records for all five records reviewed.
Facility "Medication Control-Medication Administration" policy states that "if a client is unavailable or refuses to take medication at the correct time, the Nurse or designated trained staff member shall circle and initial the med sheet and document in the comments section the reason the medication was not given". Facility "Client Self-Administration of Medication" policy states that "staff shall have the client sign the medication sheet after the medication has been taken". Additionally, policy also states that "after the client has signed the med sheet, the nurse or designated trained staff member doing the med run also signs the sheet that the proper medication has been taken".
Client # 1 was admitted on 10/9/13 and discharged on 1/7/14. Medication logs for the months of October 2013, November 2013, December 2013 and January 2014 were reviewed. The facility failed to document whether or not all medications were administered and/or the client refused medications. This client was to get the following medications; nifedipine 1 tablet daily, metoprolol 1 tablet twice daily, mirtazapine 1 tablet at bedtime, losartan 1 tablet daily, hydralazine 1 tablet three times daily.
During the month of October 2013, the facility failed to document whether this client received:
*nifedipine once daily on 10/27/13 and 10/30/13;
*metoprolol twice daily with the 8AM dose not being documented as given on 10/27/13, 10/28/13 and 10/30/13 and the 6PM does not being documented as given on 10/17/13, 10/21/13, 10/26/13, 10/30/13 and 10/31/13;
*mirtazapine at bedtime on 10/14/13, 10/21/13 and 10/26/13-10/30/13;
*losartan once daily on 10/30/13 with the staff signature was missing on 10/18/13 and 10/28/13;
*hydralazine three times daily with the 8AM dose not being documented as given on 10/18/13, 10/27/13 and 10/30/13 with the staff signature missing 10/9/13 and 10/29/13 ; the 6PM dose not being documented as given on 10/13/13, 10/14/13, 10/17/13, 10/19/13-10/23/13, 10/25/13, 10/26/13, 10/30/13 and 10/31/13; the 10PM dose not being documented as given 10/9/13-10/12/13, 10/16/13-10/18/13, 10/24/13 and 10/26/13-10/30/13.
During the month of November 2013 the facility failed to document whether this client received:
*nifedipine once daily on 11/10/13, 11/14/13, 11/23/13, 11/24/13 and 11/27/13-11/30/13.
*metoprolol twice daily with the AM dose not being documented as given on 11/10/13, 11/14/13, 11/24/13 and 11/27/13 and the PM does not being documented as given on 11/2/13, 11/16/13, 11/24/13 and 11/30/13 with the client signature missing on 11/27/13.
*mirtazapine at bedtime on 11/1/13, 11/2/13, 11/4/13-11/8/13 and 11/10/13-11/30/13.
*losartan once daily on 11/10/13, 11/14/13, 11/23/13, 11/24/13 and 11/27/13-11/30/13 with the client signature missing on 11/8/13.
*hydralazine three times daily with the 8AM dose not being documented as given on 11/10/13, 111413, 11/23/13 and 11/24/13 and the 4PM dose not being documented as given 11/1/13-11/30/13 and the 10PM dose not being documented as given 11/2/13, 11/14/13, 11/23/13, 11/24/13 and 11/27/13-11/30/13.
During the month of December, the facility facility failed to document whether this client received:
*nifedipine once daily on 12/1/13, 12/2/13, 12/21/13 and 12/27/13.
*metoprolol twice daily with the AM dose not being documented as given on 12/1/13, 12/2/131, 12/21/13, 12/26/131 and 12/27/13 and the PM does not being documented as given on 12/1/13, 12/2/13, 12/6/13, 12/7/13, 12/14/13, 12/18/13, 12/21/13, 12/22/13, 12/26/13, 12/28/13 and 12/31/13.
*mirtazapine at bedtime was missing documentation for the entire month od December 2013; losartan once daily on 12/1/13, 12/2/13, 12/21/13 and 12/27/13.
*hydralazine two times daily with the 8AM dose not being documented as given on 12/1/13 12/2/131, 12/21/13 and 12/27/13 and the 10PM dose not being documented as given on 12/1/13, 12/2/13, 12/6/13, 12/7/13, 12/14/13, 12/18/13, 12/21/13, 12/22/13, 12/28/13 and 12/31/13.
Client # 2 was admitted on 9/5/13 and discharged on 10/22/13. Medication logs for the months of September 2013 and October 2013 were reviewed. The facility failed to document whether or not all medications were administered and/or the client refused medications. This client was to get the following medications; gabapentin 300mg twice daily, gabapentin 600mg three times daily, cyclobenzaprine 1 tablet three times daily, metformin 1 tablet twice daily, risperidone 1 tablet twice daily and buspirone 2 tablets three times daily. Starting in October the following medications were added; benztropine 1 tablet twice daily and humalog 34 units in the AM and 22 units in the PM.
During the month of September 2013, the facility failed to document whether this client received:
*gabapentin 300mg twice daily with the AM dose not being documented as given on 9/29/13 with the staff signature missing on 9/12/13 and 9/17/13 and the PM dose not being documented as given 9/16/13, 9/20/13, 9/21/13, 9/24/13, 9/25/13 and 9/28/13-9/30/13. *gabapentin 600mg three times daily with the 8AM dose not being documented as given on 9/10/13 and 9/29/13 with the client signature missing 9/30/13, the 1PM dose not being documented as given on 9/8/13, 9/16/13, 9/21/13, 9/28/13 and 9/29/13 with the staff signature missing 9/30/13 and the 6PM dose not being documented as given on 9/9/13, 9/16/13, 9/21/13, 9/22/13, 9/24/13, 9/25/13, 9/28/13 and 9/29/13.
*cyclobenzaprine 1 tablet three times daily with the 8AM dose not being documented as given on 9/8/13, 9/15/13, 9/21/13, 9/24/13, 9/25/13, 9/28/13 and 9/29/13 with the staff signature missing 9/10/13-9/13/13 and 9/18/13, the 5PM dose not being documented as given on 9/7/13, 9/9/13, 9/10/13, 9/12/13, 9/13/13, 9/21/13, 9/24/13, 9/25/13, 9/28/13 and 9/29/13 with the client signature missing 9/14/13 and 9/22/13 and the 10PM dose not being documented as given on 9/6/13, 9/7/13, 9/16/13, 9/21/13, 9/23/13, 9/28/13 and 9/29/13 with the staff signature missing 9/14/13 and 9/22/13.
*metformin twice daily with the 8AM dose not being documented as given on 9/29/13 and the 5PM dose not being documented as given on 9/10/13, 9/18/13, 9/20/13, 9/21/13, 9/23/13, 9/25/13, 9/28/13 and 9/30/13.
*risperidone twice daily with the 8AM dose not being documented as given on 9/29/13 and the client signature missing on 9/19/13 and 9/30/13 and the 5PM dose not being documented as given on 9/10/13, 9/20/13, 9/21/13, 9/23/13-9/25/13 and 9/28/13 with the staff signature missing on 9/30/13.
*buspirone three times daily with the 8AM dose not being documented as given on 9/29/13 and 9/30/13, the 5PM dose not being documented as given on 9/5/13, 9/8/13-9/12/13, 9/16/13, 9/18/13-9/25/13 and 9/30/13 and the 10PM dose not being documented as given on 9/7/13, 9/14/13, 9/15/13, 9/17/13, 9/21/13, 9/23/13, 9/28/13 and 9/29/13.
During the month of October 2013, the facility failed to document whether this client received
*gabapentin twice daily with the 8AM dose not being documented as given on 10/1/13, 10/9/13, 10/18/13-10/22/13 with the client signature missing on 10/12/13 and 10/17/13, the 6PM dose not being documented as given on 10/1/13, 10/3/13, 10/4/13, 10/8/13, 10/13/13-10/15/13 and 10/17/13-10/22/13 with the staff signature missing on 10/12/13.
*gabapentin three times daily with the 8AM dose not being documented as given on 10/1/13, 10/9/13 and 10/18/13-10/22/13 with the client signature missing 10/17/13. the 1PM dose not being documented as given 10/1/13, 10/4/13-19/6/13, 10/8/13-10/10/13 and 10/17/13-10/22/13, the 6PM dose not being documented as given on 10/1/13, 10/4/13, 10/7/13, 10/8/13, 10/13/13-10/15/13 and 10/17/13-10/22/13.
*metformin twice daily with the 8AM dose not being documented as given on 10/1/13, 10/9/13 and 10/18/13-10/22/13 with the client signature missing 10/17/13, the 6PM dose not being documented as given on 10/1/13, 10/4/13, 10/8/13, 10/13/13-10/16/13 and 10/17/13-10/22/13.
*risperidone twice daily with the 8AM dose not being documented as given on 10/1/13, 10/9/13 and 10/18/13-10/22/13 with the client signature missing on 10/6/13 and the client signature missing on 10/17/13, the 10PM dose not being documented as given on 10/8/13 and 10/17/13-10/22/13.
*cyclobenzaprine three times daily with the 8AM dose not being documented as given on 10/1/13-10/7/13, 10/9/13 and 10/18/13-10/22/13 with the client signature missing 10/17/13, the 5PM dose not being documented as given on 10/1/13, 10/4/13, 10/7/13, 10/8/13, 10/13/13-10/15/13 and 10/17/13-10/22/13, the 10PM dose not being documented as given on 10/8/13 and 10/17/13-10/22/13.
*metoprolol twice daily with the 8AM dose not being documented as given on 10/1/13, 10/7/13, 10/9/13 and 10/18/13-10/22/13 with the client signature missing 10/17/13, the 6PM dose not being documented as given on 10/1/13, 10/2/13, 10/4/13, 10/5/13, 10/8/13, 10/13/13-10/15/13 and 10/17/13-10/22/13.
*benztropine twice daily with the 8AM dose not being documented as given on 10/1/13, 10/9/13 and 10/18/13-10/22/13 with the client signature missing on 10/6/13 and 10/17/13, the 10PM dose not being documented as given 10/17/13-10/22/13.
*humalog twice daily with the AM dose not being documented as given on 10/1/13, 10/9/13, 10/14/13 and 10/18/13-10/22/13 with the client signature missing on 10/6/13, 10/13/13 and 10/17/13, the PM dose not being documented as given on 10/4/13, 10/8/13, 10/13/13-10/22/13 with the client signature missing on 10/10/13.
Client # 5 was admitted on 5/22/13 and discharged on 8/22/13. Medication logs for the months of May 2013, June 2013, July 2013 and August 2013 were reviewed. The facility failed to document whether or not all medications were administered and/or the client refused medications. This client was to get the following medications; paroxetine 1 tablet at bedtime and risperidone 1 tablet at bedtime.
During the month of May 2013, the facility failed to document whether this client received
*paroxetine daily at bedtime on 5/23/13, 5/26/13, 5/29/13 and 5/30/13.
*risperidone daily at bedtime on 5/23/13, 5/26/13, 5/29/13 and 5/30/13.
During the month of June 2013, the facility failed to document whether this client received
*paroxetine daily at bedtime on 6/1/13, 6.6.13, 6/8/13, 6/9/13, 6/11/13, 6/14/13, 6/16/13, 6/18/13-6/22/13, 6/24/13-6/27/13 and 6/28/13-6/30/13.
*risperidone daily at bedtime on 6/6/13, 6/8/13, 6/10/13, 6/11/13, 6/14/13, 6/16/13, 6/18/13-6/22/13, 6/24/13-6/27/13 and 6/28/13-6/30/13.
During the month of July 2013, the facility failed to document whether this client received
*paroxetine daily at bedtime 7/1/13-7/10/13 and 7/14/13-7/31/13.
*risperidone daily at bedtime 7/1/13-7/4/13, 7/6/13-7/10/13 and 7/14/13-7/31/13.
Client # 7 was admitted on 8/21/13 and discharged on 11/20/13. Medication logs for the months of August 2013, September 2013, October 2013 and November 2013 were reviewed. The facility failed to document whether or not all medications were administered and/or the client refused medications. This client was to get the following medications; buspirone 5mg twice daily, remeron(mirtazapine) 15mg once daily and vistaril(hydroxyzine) 50mg twice daily with the change to three times daily on the October medication log.
During the month of August 2013, the facility failed to document whether this client received:
*buspirone twice daily with the AM dose not being documented as given on 8/23/13 and 8/25/13.
*vistaril twice daily with the AM dose not being documented as given on 8/23/13 and 8/27/13, the PM dose not being documented as given on 8/26/13 and 8/31/13 and the client signature was missing on 8/25/13.
During the month of September 2013, the facility failed to document whether this client received:
*buspirone twice daily with the AM dose not being documented as given on 9/14/13, 9/15/13 and 9/22/13 and the client signature was missing on 8/13/13, the PM dose not being documented as given on 9/8/13, 9/18/13 and 9/20/13 and the client signature was missing on 9/2/13.
*vistaril twice daily with the AM dose not being documented as given on 9/1/13, 9/8/13, 9/14/13, 9/16/13, and 9/22/13 and the client signature missing on 9/13/13, the PM dose not being documented as given on 9/8/13, 9/18/13 and 9/20/13 and the client signature was missing on 9/2/13.
*remeron one time daily at bedtime on 9/20/13.
During the month of October 2013, the facility failed to document whether this client received:
*buspirone twice daily with the AM dose not being documented as given on 10/1/13, 10/7/13, 10/12/13-10/15/13, 10/17/13, 10/19/13, 10/20/13, 10/23/13 and 10/25/13-10/31/13 and the client signature was missing on 10/22/13, the PM dose not being documented as given on 10/6/13, 10/17/13, 10/18/13, 10/20/13, 10/25/13-10/28/13, 10/30/13 and 10/31/13 and the staff signature was missing on 10/21/13.
*vistaril three times daily with the 8AM dose not being documented as given on 10/1/13, 10/7/13, 10/13/13-10/15/13, 10/17/13, 10/20/13, 10/22/13, 10/23/13 and 10/25/13-10/31/13 and the staff signature missing on 10/19/13, the 6PM dose not being documented as given on 10/1/13-10/18/13, 10/20/13-10/23/13 and and the staff signature was missing on 10/19/13, the 10PM dose not being documented as given on 10/1/13, 10/2/13, 10/4/13-10/20/13, 10/22/13, 10/24/13-10/28/13, 10/30/13 and 10/31/13 with the client signature missing on 10/3/13 and 10/21/13.
*remeron one time daily at bedtime on 10/6/13, 10/17/13, 10/18/13, 10/20/13, 10/25/13-10/31/13 with the client signature missing on 10/23/13 and 10/24/13.
During the month of November 2013, the facility failed to document whether this client received:
*buspirone twice daily 11/1/13-11/20/13.
*vistaril three times daily 11/1/13-11/20/13.
Client # 9 was admitted on 10/30/13 and discharged on 12/19/13. Medication logs for the months of October 2013, November 2013 and December 2013 were reviewed. The facility failed to document whether or not all medications were administered and/or the client refused medications. This client was to get the following medications; depakote(divalproex) 1 tab twice daily.
During the month of November 2013, the facility failed to document whether this client received:
*depakote twice daily with the AM dose not being documented as given on 11/1/13, 11/4/13, 11/13/13, 11/16/13, 11/20/13, 11/21/13, 11/23/13, 11/24/13, 11/26/13 and 11/28/13 and the PM dose not being documented as given on 11/2/133, 11/16/13, 11/23/13, 11/24/13, 11/27/13, 11/28/13 and 11/30/13.
During the month of December 2013, the facility failed to document whether this client received:
*depakote twice daily with the AM dose not being documented as given on 12/1/13, 12/2/13, 12/4/13-12/6/13, 12/8/13-12/19/13 and the PM dose not being documented as given on 12/2/13, 12/7/13, 12/8/13, 12/11/13, 12/14/13, 12/17/13 and 12/18/13.
The Project Director confirmed the findings.
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Plan of Correction
709.53. Client records.
The facility failed to ensure that each client had a completed medication administration record in their file. The facility failed to document whether or not all medications were administered and/or the client refused medications.
If a client is unavailable or refuses to take medication at the correct time, the designated trained staff member shall circle and initial the med sheet and document in the comments section the reason the medication was not given. Staff shall have the client sign the medication sheet after the medication has been taken. Additionally, after the client has signed the med sheet, the designated trained staff member doing the med run also signs the sheet that the proper medication has been taken.
To ensure Facility "Medication Control-Medication Administration" policy is followed training dates of 2/14/14 and 3/7/14 have been set to train designated staff. Designated trained staff member will prepare Medication Administration Log at the beginning of each month. The Facility Director will check and initial each Medication Administration Log at the beginning and at the end of each month. Facility Administrator will place Medication Administration Logs in client file at the end of each month. Refusals are to be communicated to the Program Director and Primary Counselor at the time of refusal by designated trained staff member. Designated trained staff member will inspect Medication Administration Logs daily. Quarterly audits will be conducted by the Nursing Staff.
The facility will be in full compliance by March 1, 2014.
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