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Based on record review, interview, and observation the facility failed to ensure that all medications were administered in accordance with approved policy and procedure for 7 (#1,#3,#4, #5, #6, #19, #20) of 20 patients sampled.

Findings:

Review of the MAR (medication administration record) for patient #1 reveals that Ativan 1 milligram (mg) was ordered three times a day and scheduled for 8:30 AM, 2:30 PM, and 8:30 PM. The MAR indicates that the patient received a dose of Ativan on 8/5/2010 the patient received doses at 9:18 AM, 1:41 PM, 5:16 PM, and 9:01 PM. The record also reveals that on 8/7/2010 at 8:08 AM and 8:13 PM with no dose indicated for 2:30 PM.

Review of the MAR for patient #3 reveals that the patient had Flexaril 10 mg ordered three times a day and scheduled at 8:30 AM, 2:30 PM, and 8:30 PM. The patient also had Polymyxin B/Neosporin/Cortisporin 4 drops ordered four times a day and scheduled at 8:30 AM, 12:30 PM, 4:30 PM, and 8:30 PM. The patient also had Lamictal 100 mg ordered twice a day and scheduled at 8:30 AM and 8:30 PM. The record shows that on 8/7/2010 the 8:30 AM doses of these medications were administered at 10:09 AM and that on 8/6/2010 the 8:30 AM doses were administered at 10:08 AM, over an hour past the time it was to be provided.

Review of the MAR for patient #4 reveals that the patient had Ativan 1 mg ordered 3 doses on 8/5/2010 and scheduled at 8:30 AM, 2:30 PM, and 8:30 PM. The patient also had Lamictal 100 mg ordered twice and scheduled at 8:30 AM and 8:30 PM. The patient had Tegretol 200 mg ordered twice a day and scheduled at 8:30 AM and 8:30 PM. The 8:30 AM doses on 8/5/2010 are recorded as being administered at 10:27 AM, almost two hours past the time it was to be administered.

Review of the MAR for patient #5 reveals that the patient had Risperadal 3 mg ordered twice a day and scheduled at 8:30 AM and 8:30 PM the MAR reveals doses administered on 7/29/2010 at 8:56 AM, 11:09 AM, and 9:28 PM.

Review of the MAR for patient #6 reveals that the patient had Atenolol 25 mg twice a day ordered and scheduled at 8:30 AM and 8:30 PM. The MAR indicates that the only dose given on 8/5/2010 was at 10:36 AM, two hours past the time it was to be administered; the missing dose is not indicated as being held or refused.

During medication observation on 8/12/2010 at 2:10 PM the nurse was observed to remove a unit dose packaged 1 mg Ativan from the supply and cut the tablet in half to obtain a 0.5 mg dose for patient #19. She then placed the remaining portion back into the unit dose package, placed tape over the broken seal, and returned the package to the lock box.

During medication observation on 8/12/2010 at 2:15 PM the nurse was observed to remove a previously opened package of Ativan 1 mg that had tape over the seal and remove 1/2 of a tablet that she then administered to patient #20 who was to receive a 0.5 mg dose.

During interview with the Pharmacist on 8/12/2010 at 2:30 PM he stated that when a tablet is removed from the lock box that if any portion of the medication is left after preparing the correct dosage for the patient it should be wasted in accordance with the facility policy.

The Director of Nursing stated during a telephone interview on 8/12/2010 at 3:30 PM that if any portion of a controlled drug is left after preparing the dose for the patient it should be wasted and witnessed by another nurse. She also stated that nurses sometimes are unable to record the administration of medication in the computer until some time after the dose is given and that this leads to inaccurate times in the medication administration record. She also indicated that no system is in place to document this discrepancy when it occurs. She also stated that medications should be given when scheduled.

Review of the facility's policy and procedure entitled Controlled Substances - Distribution and Administration reveals that "when the actual unit of dose to be administered and the unit withdrawn from the stock are different, the remaining amount is wasted."

Review of the facility's policy and procedure entitled medication administration and documentation reveals that "medications shall be poured and administered at the designated times."and "Each medication administered by the nurse shall be documented on the Medication Administration Record with the nurse's initials under the date and next to the time designated.

During a telephone interview with the Administrator on 8/12/2010 at 4:45 PM the Administrator stated that the nurse caring for patient #1 had documented that he had administered the 2:30 PM Ativan at 2:14 PM. He further stated that review of the surveillance video revealed that nurse had not had contact with the patient during this time. According to the Administrator, during interview with the nurse that the nurse admitted that the medication had not been administered and that he could not account for the missing medication. The administrator stated that he terminated the nurse.

Based on record review, interview, and observation the facility failed to ensure that all medical record entries were accurate and in accordance with approved policy and procedure for 5(#1, #3, #4, #5, #6) of 20 patients sampled.

Findings:

Review of the MAR (medication administration record) for patient #1 reveals that Ativan 1 milligram (mg) was ordered three times a day and scheduled for 8:30 AM, 2:30 PM, and 8:30 PM. The MAR indicates that the patient received a dose of Ativan on 8/5/2010 the patient received doses at 9:18 AM, 1:41 PM, 5:16 PM, and 9:01 PM. The record also reveals that on 8/7/2010 at 8:08 AM and 8:13 PM with no dose indicated for 2:30 PM.

Review of the MAR for patient #3 reveals that the patient had Flexaril 10 mg ordered three times a day and scheduled at 8:30 AM, 2:30 PM, and 8:30 PM. The patient also had Polymyxin B/Neosporin/Cortisporin 4 drops ordered four times a day and scheduled at 8:30 AM, 12:30 PM, 4:30 PM, and 8:30 PM. The patient also had Lamictal 100 mg ordered twice a day and scheduled at 8:30 AM and 8:30 PM. The record shows that on 8/7/2010 the 8:30 AM doses of these medications were administered at 10:09 AM and that on 8/6/2010 the 8:30 AM doses were administered at 10:08 AM, over an hour past the time it was to be provided.

Review of the MAR for patient #4 reveals that the patient had Ativan 1 mg ordered 3 doses on 8/5/2010 and scheduled at 8:30 AM, 2:30 PM, and 8:30 PM. The patient also had Lamictal 100 mg ordered twice and scheduled at 8:30 AM and 8:30 PM. The patient had Tegretol 200 mg ordered twice a day and scheduled at 8:30 AM and 8:30 PM. The 8:30 AM doses on 8/5/2010 are recorded as being administered at 10:27 AM, almost two hours past the time it was to be administered.

Review of the MAR for patient #5 reveals that the patient had Risperadal 3 mg ordered twice a day and scheduled at 8:30 AM and 8:30 PM the MAR reveals doses administered on 7/29/2010 at 8:56 AM, 11:09 AM, and 9:28 PM.

Review of the MAR for patient #6 reveals that the patient had Atenolol 25 mg twice a day ordered and scheduled at 8:30 AM and 8:30 PM. The MAR indicates that the only dose given on 8/5/2010 was at 10:36 AM, two hours past the time it was to be administered; the missing dose is not indicated as being held or refused.

The Director of Nursing stated during a telephone interview on 8/12/2010 at 3:30 PM she stated that nurses sometimes are unable to record the administration of medication in the computer until some time after the dose is given and that this leads to inaccurate times in the medication administration record. She also indicated that no system is in place to document this discrepancy when it occurs. She also stated that medications should be given when scheduled.

Review of the facility's policy and procedure entitled medication administration and documentation reveals that "medications shall be poured and administered at the designated times."and "Each medication administered by the nurse shall be documented on the Medication Administration Record with the nurse's initials under the date and next to the time designated.

During a telephone interview with the Administrator on 8/12/2010 at 4:45 PM the Administrator stated that the nurse caring for patient #1 had documented that he had administered the 2:30 PM Ativan at 2:14 PM. He further stated that review of the surveillance video revealed that nurse had not had contact with the patient during this time. According to the Administrator, during interview with the nurse that the nurse admitted that the medication had not been administered and that he could not account for the missing medication. The administrator stated that he terminated the nurse.

Based on interview and record review the facility failed to ensure that medication was removed from the pharmacy by the designated personnel, as per the facility's policies and procedures.

Findings:

During interview with the nursing supervisor on 8/12/2010 at 11:00 AM she stated that the pharmacy is only open in the afternoon and that she has to access the pharmacy multiple times per shift to obtain medications.

Interview with the pharmacist on 8/12/2010 at 2:30 PM reveals that the pharmacy can be accessed by the nursing supervisor when no pharmacist is present and that the pharmacy has no special training program for the nursing supervisors. He also stated that a review of the medications removed is done only for the purpose of reordering and is not routinely reconciled against the medications ordered for the patient.

Review of the removal of medications log by the nursing supervisor reveals that the space for patient's name is not completed, instead the unit of the medication is listed for all entries from 8/2/2010 through 8/12/2010. The log also indicates that on:
8/10/2010 at 8:30 PM 10 Neurontin 300 mg were removed;
8/11/2010 at 4:10 AM one bottle of Seroquel XL 150 milligrams (mg) was removed;
8/11/2010 at 4:10 AM 10 Dilantin 100 mg were removed ,10 Sinemet 25/100 were removed, 10 Aspirin 81 mg were removed, 4 Coumadin 5 mg were removed, 4 Coumadin 1 mg were removed, 8 Zocor 20 mg were removed, 10 Celexa 20 mg were removed, and 10 Lavert were removed:
8/12/2010 at 3:46 AM one bottle of Intuniv 1 mg was removed.

Interview with the Medical Director on 8/12/2010 at 3:30 PM reveals that he is on the pharmacy committee and that he is not aware of any studies involving after hours access to the pharmacy.

Review of the facility's policy and procedure entitled Drug Procurement by Staff Other Than The Pharmacist reveals the statements, "When a medication ordered for a specific individual is not available on the nursing unit or in the medication box, and the dose must be administered before the pharmacy opens, the nursing supervisor should enter the pharmacy." and "Obtain only the medication required for administration (plus one additional dose) until the pharmacy opens. All medications included in this directive must be in the form of dose packaging or in packet form "Sample Dose Pack" from and authorized purveyor."