|Survey Date: 9/9/2015|
Regulation Number:0564, level B scope/severity
Regulation Title: Medications - Compliance W/ Physician Orders
Regulation Description: 1.107 (5) (e) (ii) The facility shall be responsible for complying with physician orders, associated with the administration of medication or treatment, unless the resident self-administers such medication or treatment.
Based upon observation, record review and interview, the facility failed to comply with written physician orders, for the administration of medications and treatments, for five of six sample residents (#3, #4, #5, #7, #8). The findings:
1. Review of resident #3's record revealed s/he was admitted to the facility on 6/30/14 with diagnoses which included Parkinson's disease.
A written physician's order, dated 6/23/15, directed the facility to administer Carbidopa/Levodopa 25 mg - 100 mg, one tablet every twelve hours at 8:00 a.m. and 8:00 p.m. Review of the July and August 2015 medication administration records (MARs) revealed staff initials and the instructions the MARs documented the medication was administered at 8:00 a.m. and 7:00 p.m.
A QMAP (qualified medication administration person) on duty during the onsite investigation and the health and wellness director both stated the resident's evening medications were administered at 7:00 p.m. each day because the resident had requested them earlier than 8:00 p.m. There was no evidence in the resident's record the facility had requested a clarification of the order and the health and wellness director stated she had not noticed the order for the Carbodopa/Levodopa had specified the medication was to be administered every twelve hours instead of only twice per day.
2. Review of resident #4's record revealed s/he was admitted to the facility on 8/27/15 with diagnoses which included Parkinson's disease.
A written physician's order, dated 8/27/15, directed the facility to administer Estradiol (Premarin) .5 mg one tablet daily. The order was transcribed accurately on the August 2015 MAR and staff initials documented the medication was administered once daily at 8:00 a.m. from 8/28 through 8/31/15. However, a supply of Premarin .3 mg tablets was in supply. The QMAP on duty confirmed the .3 mg tablets were all that was in supply and were being administered to the resident.
3. Review of resident #5's record revealed s/he was admitted to the facility on 8/3/15 with diagnoses which included dementia.
A written physician's order, dated 8/12/15, directed the facility to administer Buspar 10 mg, one tablet every eight hours. Review of the August 2015 MAR revealed staff initials and the instructions the MARs documented the medication was administered at 8:00 a.m., 2:00 p.m. and 8:00 p.m.
4. Review of resident #7's record revealed s/he was admitted to the facility on 8/10/15 with diagnoses which included Parkinson's with dementia.
A written physician's order, dated 7/20/15, directed the facility to administer Myrbetriq extended release 50 mg, one tablet daily. Review of the August 2015 MAR revealed the medication was discontinued on 8/25/15. Instructions to discontinue the medication, dated 8/25/15, were found in the resident's record that were written on an authorized practitioner's prescription pad; however, the instructions were not signed. The health and wellness director stated she had not noticed that the instructions had not been signed and confirmed that the medication was discontinued on 8/25/15.
5. Review of resident #8's record revealed s/he was admitted to the facility on 3/13/15 with diagnoses including Alzheimer's dementia.
A written physician's order, dated 8/11/15, directed the facility to administer Seroquel 25 mg, one tablet twice daily. Staff initials and instructions on the August 2015 MAR documented the medication was administered as 25 mg, one-half tablet from 8/11/15 through the morning of 8/31/15. A supply of Seroquel 25 mg, half-tablets was found in the residents medication supply. A QMAP on duty during the onsite investigation stated the resident had been administered only one-half tablet as indicated on the MAR. The health and wellness director stated that she was not sure why the resident's medical practitioner wrote the order for a full 25 mg tablet was to be administered, believing the order to be a "mistake:" however, she conceded there was no evidence the facility had attempted to obtain clarification from the resident's medical practitioner.
Facility Plan of Correction:
P564 Medication- Compliance with MD Orders
Resident #3 Order obtained on 9/9/215 for Carbidopa/Levothyroxine to be administered bid
Resident #4 Order clarification obtained on 9/9/2015 regarding Estradiol dosage
Resident #5 Order obtained on 9/9/2015 re: Buspar time to be administered
Resident #7 Order obtained on 9/9/2015 that Myrbetriq was d/c
Resident #8 Order clarification obtained on Seroquel dosage
The Health and Wellness Director (HWD) will receive re-training on the Medication and Treatment- Medication Administration Record and Transcription of Orders on Nov 3, 2015 by the District Director Clinical Services (DDCS). ED or designee to monitor for compliance by medication orders with the MAR. DDCS to complete random record review to monitor for compliance at routine site visits.
(1.What process improvements or system changes have or will be implemented to ensure that QMAP staff are administering medications as ordered by the physician?)
HWD will conduct weekly Q-map meetings for continued training and consistancy. Daily MAR audits will be conducted at each shift change to address any concerns and a sign off sheet used at each shift change.
(2.Regarding the monitoring, will the review also include a review of the medication in the supply to ensure all match? How often will the monitoring be occurring, random during site visits, is not a sufficient frequency. How will the monitoring be documented?)
Weekly MAR/Cart autidts will be done by HWD and lead QMAP to ensure MAR, orders and supply all match. Weekly reports will be sent to DDCS on all MAR/Cart audits and results. The DDCS snd DDO will conduct bi-annually visits that will be documented on the site visit form. More frequent visits will be made if needed.