HospitalInspections.org

Based on observation, interview, and record review, facility staff failed to document dispensing a narcotic in the narcotic logbook and failed to identify the narcotic count was incorrect within the narcotic logbook prior to dispensing a narcotic for 1 (#8) of 8 sampled patients; facility staff failed to review a patient's medication order prior to overriding a warning message for medication dosing for 1 (#2) of 8 sampled patients; and the facility failed to implement a process for verification of physician orders accuracy within the electronic medical record (EMR). These deficient practices had the potential to affect all patients' receiving medication at the facility. Findings include:

1. During an observation and interview on 5/5/25 at 2:48 p.m., staff member D unlocked the medication cart narcotic drawer. Staff member D stated a narcotic count was done twice a day at shift change. Staff member D stated the night nurse was responsible for removing the narcotic medication and dispensing it to the appropriate medication carts. Staff member D began counting narcotics as the surveyor confirmed the counts were correct within the narcotic logbook. Staff member D noted the narcotic count was incorrect for patient #8's Tramadol 50mg tablets. The narcotic count sheet indicated the count should have been 62 tablets and the pill count was 61. The last dose of Tramadol 50 mg was given on 5/5/25 at 2:44 p.m. by staff member E. Staff member D said she had given patient #8 his dose of Tramadol 50 mg for his 8:00 a.m. medication pass. She then took the narcotic logbook and entered the dose she had missed. Staff member D did not confirm the dose was documented in the EMR.

During an interview on 5/6/25 at 9:08 a.m., staff member B said the missed narcotic count would have been caught with the change of shift count and no one would have been allowed to go home until the medication was accounted for and documented.

During an interview on 5/6/25 at 9:23 a.m., staff member C said it was her expectation that medication would be recorded when it was removed, prior to use. Staff member C stated the medication should have been documented in the narcotic log.

During an interview on 5/6/25 at 3:46 p.m., staff member E said she usually would check to see if the narcotic count was correct prior to dispensing medication. She stated she must not have checked.

2. During an observation and interview on 5/7/25 at 11:34 a.m., staff member K removed patient #2's gabapentin pill card from the locked narcotic drawer. Staff member K then scanned the medication into the EMR. A large yellow triangle with an exclamation sign appeared on the screen indicating that the medication timing was too soon after the previous dose was administered. Staff member K then proceeded to override the system and was about to dispense a second dose of gabapentin 600 mg. Staff member K was asked when the last dose of gabapentin was administered. The EMR indicated the previous dose of gabapentin 600 mg was administered at 9:18 a.m. Staff member K said patient #2 was to receive the medication three times a day. Staff member K was asked if two hours between doses would be correct for a three-times daily order. Staff member K cancelled the administration for patient #2.

During an interview on 5/7/25 at 1:48 p.m., staff member C said patient #2 was transferred from another facility. The EMR system would usually transfer over the orders for the patient's medication, but because their facility does not supply the medication and it is supplied by a local outpatient pharmacy, the patient was discharged from care and the EMR transferred the medication orders as a prescription to the outpatient pharmacy. The medication order was transcribed incorrectly, and the transcription did not get the original prescription by the provider correct. The information was never relayed to be specific for a morning dose, evening dose and bedtime dose. It was sent and was written as three times a day. Staff member C said the facility had noted similar errors in the past and the process was being "worked on".

Record review of patient #2's EMR showed an order for gabapentin 300mg, take 2 capsules by mouth in the morning, 2 capsules in the evening, and 2 capsules before bedtime, with a start date of 3/25/25.

Record review of patient #2's medication administration record showed an order for gabapentin 300mg, 2 capsules, three times daily.

Review of a facility document, "Medication Administration", dated 11/2016, showed:

" ...Policy
The focus of medication administration is to ensure the process is performed correctly, safely and without errors while maintaining the security of the medications. Medications pass process will focus on the established standard of practice that includes the Seven Rights of Medication Administration:
-Right Resident
-Right Drug
-Right Dose
-Right Route
-Right Time
-Right Documentation
-Right Evaluation of Efficacy of the medication ...
...Before medications are administered, they are to be signed off immediately prior to giving-not at the end of the medication pass. ..."