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Based on interview and record review, the facility failed to ensure they developed and implemented a system for addressing medication administration errors including identification, assessment, and documention for 2 (#s 2 and 5) of 6 sampled patients. The deficient practice had the potential to affect all patients receiving pharmacy services. Findings include:

Review of a Facility-Reported Incident, dated 10/3/24, showed three separate medication errors occurred on 9/28/24. The report showed patient #2 received two oxycodone 5 mg tablets, at 8:00 a.m. on 9/28/24, rather than the one tablet ordered by the provider. The report also showed patient #5 did not receive her clonazepam 1 mg or her lacosamide 50 mg at 8:00 a.m. on 9/28/24, as ordered by the provider.

During an interview on 11/5/24 at 11:12 a.m., staff member E stated she worked the night shift on 9/28/24 through 9/29/24, and followed an agency RN. Staff member E stated during the shift change narcotic count, the day RN told her she gave an extra oxycodone 5 mg to patient #2 at 8:00 a.m. on 9/28/24. The day RN told staff member E the provider would "okay it." Staff member E confirmed two oxycodone were signed out at 8:00 a.m. on 9/28/24. Staff member E stated when cleaning off the top of the medication cart, she found two unidentified pills in a medication cup. Staff member E stated she used a pharmacy reference and determined the medications were clonazepam 1 mg and lacosamide 50 mg. Staff member E stated she decided the medications belonged to patient #5 and should have been given at 8:00 a.m. on 9/28/24. Staff member E stated she notified the administrator, the medical provider, and each patient's family member of the medication errors.

During an interview on 11/5/24 at 9:00 a.m., staff member H stated he should have been notified of the medication errors involving patient #s 2 and 5. Staff member H stated he had not been notified of any of the medication errors which occurred on 9/28/24.

During an interview on 11/8/24 at 10:20 a.m., staff member G stated when a medication error occurs, the provider, the patient's family, and the DON were notified. Staff member G stated there was a medication error form which was also filled out.

Review of patient #2's narcotic sign out logs, dated 9/15/24 and 9/16/24, showed two doses of oxycodone 5 mg were signed out at 8:00 a.m. on 9/28/24, resulting in a medication error.

Review of patient #2's MAR, dated September of 2024, showed the patient had an order for oxycodone 5 mg, one tablet to be given every six hours as needed for pain. The MAR failed to show the patient received two oxycodone 5 mg tablets at 8:00 a.m. on 9/28/24.

Review of patient #2's EHR failed to show an order from the provider allowing two oxycodone 5 mg to be given at the same time. The nursing progress notes failed to show the provider and the patient's family were notified of the medication error.

Review of patient #5's narcotic sign out logs, dated 8/29/24 and 9/9/24, showed a dose of clonazepam 1mg and a dose of lacosamide 50 mg were signed out at 8:00 a.m. on 9/28/24.

Review of patient #5's MAR, dated Sepetember 2024, showed the patient received clonazepam 1mg and lacosamide 50 mg at 8:00 a.m. on 9/28/24.

Review of the patient's EHR failed to show the medication doses found on the medication cart by staff member E were not given as ordered at 8:00 a.m. on 9/28/24. The EHR failed to show the provider or the patient's family was notified of the two medication errors.

Review of the facility's policy titled, "Pharmacy," dated 8/22/22, showed, "All definite, possible, or indication of an advers drug event shall be Explained on an adverse drug event form and reported to the attending Physician, ... and will be noted in the nurses' notes. ... the Pharmacist will be notified." [sic] The policy failed to show how a medication error was documented in the EHR.

A request was made on 11/5/24 and 11/7/24 for the facility's Medication Error policy. Nothing was provided by the end of the survey.

Based on interview and record review, the facility failed to ensure all patient medical records are complete and accurate for 3 (#s 2, 3 and 5) of 6 sampled patients. Medication errors occurred for patient #s 2 and 5 and patient #3 experienced an unwitnessed fall. Findings include:

Review of the investigative file for a Facility-Reported Incident, dated 10/3/24, showed two patients (#s 2 and 5) were involved in medication administration errors on 9/28/24. The file also showed resident #3 had sustained a fall on 9/28/24.

Medication Errors
During an interview on 11/5/24 at 9:00 a.m., staff member H stated he should have been notified of the medication errors involving patient #s 2 and 5.

During an interview on 11/5/24 at 11:12 a.m., staff member E stated she worked the night shift on 9/28/24 through 9/29/24, and had found the medication errors involving patient #s 2 and 5. Staff member E stated she had notified the on-call provider regarding the extra oxycodone dose for patient #2, the missed doses of lacosamide and clonazepam for patient #5, and the fall sustained by patient #3. Staff member E stated she notified the administrator of the incidents which occurred on 9/28/24.

Review of patient #2's EHR failed to show any progress notes involving the medication error which occurred on 9/28/24. The EHR failed to show the patient had received two oxycodone 5 mg tablets at 8:00 a.m. and failed to show the notifications to the administrator, the provider, and the family.

Review of patient #2's MAR, dated September of 2024, showed only one dose of oxycodone 5 mg was given at 8:00 a.m. on 9/28/24.

Review of patient #2's provider orders failed to show an order allowing the extra dose of oxycocone 5 mg given on 9/28/24.

Review of patient #5's EHR failed to show any progress notes involving the medications which were missed on 9/28/24 at 8:00 a.m.

Review of patient #5's MAR, dated September of 2024, showed the 8:00 a.m. doses of clonazepam and lacosamide were given as ordered on 9/28/24.

Refer to C-1016 Patient Care Policies for additional detail regarding the medication errors which occurred.

Patient Falls
During an interview on 11/5/24 at 10:35 a.m., staff member D stated staff member F told her about patient #3's fall on 9/28/24.

During an interview on 11/5/24 at 11:12 a.m., staff member E stated she had been notified of patient #3's fall on 9/28/24.

Review of patient #3's EHR failed to show any documentation of the fall which occurred on the morning of 9/28/24. The EHR also failed to show any post fall assessments, or any provider or family notifications.

Review of the facility's policy titled, "Nursing Assessment After A Fall," dated 8/30/22, showed, "... 2. The charge nurse will assess resident (patient) for any injury, notify the medical provider and the family and document the aforementioned information in the nurse's notes."

Review of the facility's policy titled, "Alert Charting," dated 8/14/22, showed falls were one of the reasons alert charting was initiated. The alert charting should have included vital signs every shift for three days, daily charting of any observations of pain, bruising, or any injuries related to the fall, and notification of the medical provider and family.