Elm Manor Nursing and Rehabilitation Center
September 14, 2018 Complaint Survey

Standard Health Citations

FF11 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 14, 2018
Corrected date: November 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 805) completed on 9/14/18, it was determined that for two of three residents reviewed for pharmacy services, the facility did not ensure that medications were available and provided to meet the needs of each resident. Specifically, dementia medication, pain patch, and vitamin supplement were not available (Resident #1), and a pain patch was not available (Resident #2). This is evidenced by the following: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/21/18, revealed the resident was cognitively intact. The current physician orders [REDACTED]. An Integrated Progress Note, dated 7/10/18, documented that the facility was out of Memantine, the pharmacy was notified, and a refill had been requested two times prior to that call. The pharmacy stated that the medication would be delivered by the next morning. A review of the (MONTH) (YEAR) Medication Administration Record (MAR) revealed Memantine was circled as not given from 7/8/18 through 7/11/18. A review of the (MONTH) (YEAR) MAR revealed a pain patch was not administered on 8/1/18 or 8/2/18, and vitamin D was not given on 8/5/18, 8/6/18, and 8/7/18. The back of the MAR revealed an entry, dated 8/3/18, that a pain patch was placed in the evening. Interviews conducted on 8/7/18 included the following: a. At 9:53 a.m., the Director of Nursing (DON) said the facility switched to a new pharmacy on 6/1/18. She said there were multiple problems with the new pharmacy including a lack of timely deliveries or medications not being delivered at all. The DON said that medications are being delivered from New Jersey. The DON said if a medication is ordered by 1:00 p.m., it is supposed to be delivered that day or at least by the next day. She said the pharmacy is not always receiving fax transmissions from the facility, and recently someone had looked at the facility fax and found a problem in the line. The DON said if a medication error is brought to her attention, she will re-educate and find out what happened. She said if a medication is not given, it should be circled on the MAR. b. At 10:55 a.m., the resident said there had been a couple of times her medications were not available, including her dementia medication and her pain patch. She said she receives a dementia drug to treat Alzheimer's, and when she does not get the medication, she feels dizzy and has nightmares. The resident said she recently went without her pain patches for several days and had been in a lot of discomfort. She said she needs both the pain patch and Tylenol ([MEDICATION NAME]) to manage her pain and keep it at a tolerable level. She said without either one of these medications, her pain goes right up to an 8 out of 10. c. At 11:16 a.m., a Registered Nurse Manager (RNM) said there is a new pharmacy and it is set up to deliver medications for new admissions right away. She said the pharmacy reported to the facility that sometimes they are not receiving the faxes. She said the facility now keeps a copy of all fax transmittals. The RNM said one fax machine had been replaced and the other one does not always transmit. She said to verify transmittals, the nurses are to check that the fax was sent and received, check the paperwork submission on the fax transmittal (date received), and call the pharmacy after a fax to confirm receipt of submission. The RNM said that this is not a seamless process and there are still kinks to work out. She said delivery times are inconsistent but if medications are ordered by 11:00 a.m., delivery is expected between 3:00 p.m. and 3:30 p.m. The RNM said sometimes intravenous medications and antibiotics with a half-life are not sent at all or do not arrive until after 5:00 p.m. d. At 1:00 p.m., Licensed Practical Nurse (LPN) #1 said a circle on the MAR means a medication was not given. LPN #1 reviewed the (MONTH) (YEAR) MAR and said she had circled and initialed 7/8/18 through 7/12/18 that Memantine was not given and the resident had missed four doses. An undated entry on the back of the MAR revealed that the medication was unavailable and a refill request was faxed to the pharmacy. LPN #1 said she does not chart the reason that a medication was not given in the progress note. She said sometimes she writes on the back of the MAR the reason the medication was not given. LPN #1 said that she does not always tell a Registered Nurse (RN) when medications are missing, it all depends on what the medication is, and she usually goes a couple of days before reporting that a medication is unavailable. e. At 1:10 p.m., LPN #2 said she circles the MAR when a medication is not given but does not always document a reason on the back of the MAR. She said she usually tells an RN but does noy notify a medical provider. LPN #2 said she has called the pharmacy to ask about medications but they never answer the phone. f. At 1:16 p.m., the DON said she found out about the pain patch missing on 8/3/18 because she was working the medication cart that evening and did not have a patch. She said another nurse placed the patch when it arrived later that evening. The DON said when a medication is missing, she expects the nurse to order it from the pharmacy and notify an RN. The DON said she is notified when a medication is two or more days out of stock and has not been delivered. The DON said that every medication is to be available and given per physician order. She said that the pain patch is an over the counter product and the facility could have purchased it at a local pharmacy. The DON said LPN #1 had re-ordered vitamin D3 but the fax did not go through and it was faxed again. A RNM joined the interview and said staff are supposed to notify her of missing medications so that she can notify the pharmacy. The RNM said she tells the nurses to order medications when there is a seven day supply left. The DON said there is no contract with a local pharmacy for back-up. A review of Re-Order Medication Forms revealed the following: a. Memantine was ordered on [DATE], 7/10/18, and 7/11/18. A packing slip, dated 7/11/18, revealed the medication was delivered that date. b. The [MEDICATION NAME] Patch was ordered on [DATE], 8/2/18, and 8/3/18. A packing slip, dated 8/3/18, revealed delivery that date. c. Vitamin D3 2,00 units was ordered 8/4/18, and Vitamin D3 1,000 units was ordered on [DATE]. A packing slip, dated 8/7/18, revealed delivery of Vitamin D3 1,000 units. (Resident #1's order is for 2,000 units daily). 2. Resident #2 was admitted to the facility on [DATE] for short term rehab with [DIAGNOSES REDACTED]. A MDS Assessment, dated 4/12/18, revealed the resident was cognitively intact. Physician orders, dated 4/5/18, directed [MEDICATION NAME] 5 percent patch on/off every 12 hours. A Medical Assessment, dated 4/6/18, revealed that a pain management program was in effect, and the resident had a positive effect with the use of the [MEDICATION NAME]. Physician orders [REDACTED]. A pharmacy shipment summary, dated 4/5/18 at 9:50 p.m., revealed the delivery of 30 [MEDICATION NAME] 5 percent patches for the resident. Review of the (MONTH) (YEAR) MAR revealed the first patch was placed on 4/7/18 at 9:00 a.m. In an interview on 8/8/18 at 12:40 p.m., the RNM said [MEDICATION NAME] was ordered on [DATE] but she did not know when it was received. The RNM reviewed the (MONTH) (YEAR) MAR and said the patch was not available at least for one day and she did not know why. When interviewed on 8/8/18 at 11:33 a.m., a Physician Assistant (PA) said she has been notified almost every day she is onsite of medications not delivered on time and residents going without medications. The PA said medications are to be given as ordered. She said there have been so many missing medications that she could not even specify what was missing, both significant and not significant. She said there has not been any harm because of missing medications. The PA said if staff are missing a medication, she would expect the nurses to start by contacting the pharmacy to find out why and then notify her, so she could order an alternative, maybe even for a local pharmacy pick-up. (10 NYCRR 415.18(b)(1)(2)(3))

Plan of Correction: ApprovedOctober 10, 2018

Immediate Corrective Action
Resident # 1 was seen by the Medical Provider and no adverse effects was found by this omission.
Resident #2 was seen by the Medical Provider and on a 3 day pain study no adverse effects were found by this omission.
The Director of Nursing reviewed the policy and procedure for Medication Ordering from Pharmacy and updated the policy to include the following:
? Place a follow-up phone call to the pharmacy to ensure re-order sheet was received
? If fax not received by pharmacy give all re-order medications verbally to the pharmacy representative
The Director of Nursing reviewed the policy and procedure for Missing Medication, Medication Occurrence Policy and form and Transcription of Physician Orders.
Identification of Others
The Director of Nursing/Nurse Educator or designee will audit all medical records to ensure no additional medications were not available as ordered by medical. All negative findings will be corrected immediately.

Systemic Changes
Specialty Pharmacy provided a scanner for all medication orders to be scanned directly to the pharmacy system.
Specialty Pharmacy Representative does weekly visits to ensure quality of services to include the following:
? All ordered medications orders are being delivered
? Medications are being ordered in a timely manner to ensure availability
Quality Assurance
All licensed nursing staff was in-serviced and educated on the updated policy of Medication Ordering from Pharmacy and the policy and procedure for Missing Medication, Medication Occurrence Policy and form and Transcription of Physician Orders
The Director of Nursing will create an audit tool to be conducted by the Nurse Manager or Designee on a weekly basis for three (3) months. Ten (10) resident medication administration records will be randomly selected for the audit. After the three months, this audit will be continued monthly.
The Director of Nursing will be responsible for the correction of this deficiency.

FF11 483.45(f)(2):RESIDENTS ARE FREE OF SIGNIFICANT MED ERRORS

REGULATION: The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 14, 2018
Corrected date: November 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during an Abbreviated Survey (complaint NY# 805) completed on 9/14/18, it was determined that for one (Resident #3) of three residents reviewed for medications, the facility did not ensure that each resident was free from significant medication errors. Specifically, the facility identified a medication transcription error for an anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) on 7/13/18, clarified the medication order that date, and continued to administer the wrong dose until 8/9/18. This is evidenced by the following: A facility policy, Transcription of Physician Orders, dated 7/1/18, revealed that physician orders [REDACTED]. A Licensed Nurse, Registered Nurse (RN) or Licensed Practical Nurse (LPN) must transcribe all physician orders [REDACTED]. When transcribing orders, the medication order is transcribed onto the Medication Administration Record (MAR). The nurse transcribing the order writes the date of the order on the left side of the MAR and must specify medication name, dosage, route of administration, frequency, reason for medication and time of the medication administration. After transcription, orders are faxed to the pharmacy. A second order check will be completed by the alternating nurse on the same shift. The night nurse will review each resident's chart to ensure all physician orders [REDACTED]. If an error has been found, the night nurse will make the appropriate correction, generate a medication error form, and forward it to the Director of Nursing (DON). Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/6/18, revealed the resident has severely impaired cognition. A Medication Irregularity Report, dated 7/13/18, revealed that too much [MEDICATION NAME] and [MEDICATION NAME] were given, not enough [MEDICATION NAME] was given, and staff were re-educated. Physician orders, dated 7/13/18, included [MEDICATION NAME] 250 milligrams (mg) per 5 milliliters (ml) (250 mgs/5 mls) give 500 mgs (10 mls) every morning and 1,500 mgs (30 mls) every evening. The (MONTH) (YEAR) MAR and (MONTH) (YEAR) MAR documented that [MEDICATION NAME] was given as ordered. A review of the pharmacy delivery slips revealed that one bottle of [MEDICATION NAME] (473 mls) was delivered on 6/29/18 and 7/30/18. Interviews conducted on 8/9/18 included the following: a. At 3:57 p.m., a Registered Pharmacist said that [MEDICATION NAME] was a significant medication. She said the facility had originally ordered [MEDICATION NAME] on 6/29/18 and one refill bottle had been ordered and was delivered on 7/30/18. The Registered Pharmacist said each bottle holds 473 mls, so given at 40 mls per day, a bottle would last approximately 11 days. The pharmacist said it appeared that this medication was still not being given as ordered and that the refill of 7/30/18 should be close to empty. b. At 4:26 p.m., a RN Manager (RNM) said she was administering medications that evening and would verify the amount of [MEDICATION NAME]. She retrieved the in-use bottle and said it was dated 7/31/18 and was almost full. She said the bottle should be almost empty. The RNM said the medication could not have been given as ordered, and she would start an investigation immediately. When interviewed on 8/10/18 at 11:14 a.m., the Director of Nursing (DON) said she calculated that the first bottle of [MEDICATION NAME] should have been used up by 7/22/18. The DON said the bottle in the medication cart was dated as opened on 7/30/18. The DON said she had reviewed the pharmacy delivery slips and one bottle of [MEDICATION NAME] had been delivered on 6/29/18 and the other on 7/30/18. She said she was starting a medication error investigation to determine how much [MEDICATION NAME] was actually given versus what was ordered. During an interview on 8/13/18 at 11:59 a.m., the DON and RNM said that was simple math and the nurses should have caught the dispensing error. They said staff will need to be re-educated. (10 NYCRR 415.12(m)(2))

Plan of Correction: ApprovedOctober 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Correction Action
Resident # 3 was seen by Medical Provider and no adverse effects were found by this error.
The Director of Nursing reviewed the policy and procedure for Administering Medications no changes were made to the policy, Medication Error Form and Transcription of Physician Orders.
Identification of Others
The Director of Nursing/Nurse Educator or designee will audit all Medication Administration Records against the medication blister packs to ensure Medication Administration records and medication blister packs labels match. All negative findings will be corrected immediately.
Systemic Changes
The Director of Nursing reviewed the policy and procedure for Administering Medications and transcription of Physician order [REDACTED]. The Director of Nursing provided the licensed nursing staff with education on F 760 and the failure to follow the Administering Medications policy and procedure focusing on the five (5) rights.
Quality Assurance
All licensed nursing staff was in-serviced and educated on the Administrating Medications and
Medication Error Form.
The Director of Nursing will create an audit tool to be conducted by the Nurse Manager or Designee on a weekly basis for three (3) months. Ten (10) resident medication administration records and medication blister packs will be randomly selected for the audit. After the three months, this audit will be continued monthly.
The Director of Nursing will be responsible for the correction of this deficiency.