Health inspection·October 20, 2022

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to ensure an accurate count and reconciliation of controlled drugs (narcotics) for 1 of 4 sampled residents (Resident #290). The facility also failed to follow their own policy and process for disposition of controlled drugs for 2 of 2 sampled discharged residents (Residents #342 and #65). The findings included: Review of the policy Discontinued Medications revised April 2007 documented, Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. 3. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. On 10/20/22 at 2:57 PM, the Director of Nursing (DON) provided the above policy as had been requested earlier that day. When asked if there was an established policy as noted in the above Discontinued Medication policy, that further instructed the process for discontinued controlled medications, or any policy for the narcotic count process, or the documentation of controlled medications, the DON stated there was not. 1. An observation and random narcotic reconciliation was made on 10/20/22 beginning at 12:21 PM, for the 2 South medication cart, with Staff A, a Licensed Practical Nurse (LPN). The surveyor obtained the narcotic book (a binder that contained the Controlled Drug disposition sheets for all current residents who had orders for narcotics), turned to the Controlled Drug Disposition sheet for Resident #290, and asked Staff A the number of Oxycodone/APAP (a narcotic pain medication) 7.5/325 mg (milligram) tablets that were on hand. Staff A stated there were 14 tablets, the surveyor also observed 14 tablets in the bubble pack (the card that contained the medication), but the Controlled Drug Disposition sheet documented 15 tablets remained (Photographic Evidence Obtained). The LPN stated, Oh, I gave it this morning and must have forgotten to sign it out, and began to sign it out on the Controlled Drug Disposition sheet. Staff A looked up the administration record for the Oxycodone/APAP for Resident #290 in the electronic record, noted the time of administration as 8:52 AM that same morning. Staff A then stated she did sign out that morning's dose, showing the surveyor the last completed documentation on the Controlled Drug Disposition sheet, that matched the current Medication Administration Record (MAR) except she had documented the wrong date of 10/19/22. Staff A further explained during change of shift that morning, Resident #290 asked for the pain medication, but Staff B, a Registered Nurse (RN)/the night nurse, stated she had given the medication at 2 AM, thus it was not due until 8 AM. Staff A was then asked to explain how they completed the Page 1 of 3 105125 105125 10/20/2022 Terraces of Lake Worth Care Center and Rehab 1711 6th Avenue South Lake Worth, FL 33460

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning narcotic count. Staff A stated Staff B, the night nurse read off the Controlled Drug Disposition sheets the name of the resident, the medication and the number of pills left as per the record, and she (Staff A) confirmed the number of pills in each pill pack in the medication cart. When asked how they reconciled the Oxycodone/APAP for Resident #290, Staff A stated, I'm pretty sure she said 15 which would have been the count before the 8:52 AM administration, although the documentation on the Controlled Drug Disposition sheet during change of shift would have been 16 tablets remaining. Upon further review of the Controlled Drug Disposition sheet and the current MAR, it was determined Staff B, the night nurse failed to sign out the 2 AM dose of Oxycodone/APAP for Resident #290 on the Controlled Drug Disposition sheet. The second floor Unit Manager overheard the conversation and was also at the medication cart. The Unit Manager agreed with the discrepancy, and stated, I've already called the night nurse and she is on her way in. During an interview on 10/20/22 at 1:19 PM, Staff B, the RN/night nurse, was asked what happened with the Oxycodone for Resident #290. Staff B explained she gave Resident #290 an Oxycodone at 2 AM and forgot to sign it out on the Controlled Drug Disposition sheet. Staff B stated she worked a double (starting at 3 PM on 10/19/22 through 7 AM on 10/20/22), and it was a crazy night. When asked how they did the count and reconciled the medications when the count did not match, the RN stated, I don't know. I was so tired this morning. 2. During the continued random narcotic reconciliation with Staff A, beginning on 10/20/22 at 12:21 PM for the 2 South medication cart, the surveyor noted a Controlled Drug Disposition sheet for Resident #342 in the narcotic binder, for Alprazolam 0.25 mg (Xanax, an antianxiety controlled medication). Upon trying to review the current electronic MAR, the surveyor was unable to locate the resident in the current resident list. When asked about Resident #342, the Unit Manager explained Resident #342 had been discharged to the hospital, and probably was going to be admitted to Hospice services, and possibly not returning. During an interview on 10/20/22 at 12:48 PM, the Unit Manager was asked the process for disposition of controlled medications when a resident is transferred or discharged from the facility. The Unit Manager explained the nurse (who discharged the resident or the next shift nurse if the resident was discharged during the night) should give the medication to the Unit Manager, who would then give it to the Director of Nursing (DON) for proper disposition. Review of a discharge progress note, dated 10/16/22 at 9:33 AM, revealed Resident #342 was discharged to the hospital, four days earlier. 3. An observation and random narcotic reconciliation was made on 10/20/22 at 1:00 PM, with Staff C, LPN, for the 2 North medication cart. Upon surveyor arrival to the cart, the LPN was pulling controlled drugs from the medication cart's lock box. Review of the two bubble packs just retrieved from the cart by Staff C, revealed Oxycodone IR (a narcotic pain medication) 5 mg and Hydrocodone/APAP (a narcotic pain medication) 5/325 mg for Resident #65. Resident #65 had been discharged from the facility on 10/17/22, three days earlier. When asked the process for disposition of controlled drugs for a resident who had been discharged , the LPN stated within a day or two she should give the narcotics to the Unit Manager. When asked if she worked 10/17/22, Staff C stated she had, but Resident #65 was discharged late that day. Staff C confirmed she worked the next day on 10/18/22, and when asked why the narcotics hadn't been removed from the medication cart for Resident #65, the LPN stated she had been busy. Review of the record revealed Resident #65 had an order dated 10/14/22 for a planned discharge on 105125 Page 2 of 3 105125 10/20/2022 Terraces of Lake Worth Care Center and Rehab 1711 6th Avenue South Lake Worth, FL 33460

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE]. A progress note by Staff C on 10/17/22 at 3:02 PM revealed Resident #65 went to dialysis earlier that day and would be going directly home from the dialysis facility. Further review of the orders revealed the dialysis pick-up time for Resident #65 was 1:30 PM, indicating the resident was discharged from the facility during the afternoon of 10/16/22, while Staff C was working. During an interview on 10/20/22 at 2:57 PM, the DON was asked the disposition process for controlled medications for any resident transferred or discharged from the facility. The DON stated when a resident leaves the facility, she herself takes the narcotics off the cart within 24 hours of the discharge. The DON explained she and the direct care nurse would both sign off, and the controlled medication would go into a lock box in the DON's office until the Consultant Pharmacist was available for proper disposition. The DON was made aware of the contradictory process verbalized by the nursing staff on the second floor. 105125 Page 3 of 3