145702
11/12/2024
Fair Oaks Rehab & Healthcare
1515 Blackhawk Boulevard South Beloit, IL 61080
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Based on interview and record review, the facility failed to maintain reconciliation of a controlled narcotic medication. This failure has the potential to affect all 14 residents (R1-R14) that reside in the facility and have a current order for the narcotic. This past non compliance occured from October 25, 2024-November 5, 2024. The findings include: The Order Listing Report, dated November 12, 2024, shows R1-R14 have current orders for hydrocodone/Norco either scheduled or as needed. The facility's State Report, dated October 29, 2024, shows, It was reported to the ADON (Assistant Director of Nursing) that eight tablets of hydrocodone (Norco) that were sent for the stat safe (emergency backup storage) were missing. The hydrocodone was delivered on Friday evening October 25, 2024 and signed for by the nurse working in the front of the building. She then took the delivery to the nurse in the back to drop it into the stat safe. To put medications in the stat safe, there must be two nurses with log in access from the pharmacy. The nurse that was working with her did not have access. The package was placed in the locked med room .On Monday morning another nurse was notified by the pharmacy that the medication had not yet been dropped into the safe. The nurse notified the ADON. On November 12, 2024 at 8:38 AM, V1, Administrator, said the pharmacy delivered a Norco pack for the facility's stat safe on October 25, 2024. V5, LPN (Licensed Practical Nurse), signed for the Norco/accepted the delivery and took it to V6, RN (Registered Nurse), that was working the back hall and near the stat safe. V6 went to drop the Norco and realized she needed two nurses to drop it, and the other nurse on duty did not have access, so V6 left the Norco on top of the stat safe. Pharmacy called the facility the following Monday on October 28, 2024 and said they had noticed it was not dropped into the safe. V3, ADON, began an investigation. V1 said staff searched everywhere for the narcotic and could not find it. V1 said as of November 12, 2024, the narcotic is still unaccounted for. V1 said all staff present were drug tested and the facility was still waiting on three drug test results. V1 said all nursing staff now have access to the stat safe and inservices were provided November 5, 2024. On November 12, 2024 at 9:25 AM, V5, LPN, said she signed for the narcotic when pharmacy delivered it on October 25, 2024. V5 said she did not have access for the stat safe, so she brought the narcotic to V6, RN, to drop it into the stat safe. V5 said that V6 was administering medications to a resident, so V5 gave the narcotic to V6 and then went to finish her assignment.
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145702
145702
11/12/2024
Fair Oaks Rehab & Healthcare
1515 Blackhawk Boulevard South Beloit, IL 61080
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
On November 12, 2024 at 9:45 AM, V6, RN, said on Friday evening, October 25, 2024, V5 brought V6 eight Norco and V6 placed the narcotic on top of the stat safe. V6 said neither nurse she was working with had access to the stat safe, so she just put it on top of the stat safe. V6 said she worked PM'S and night shift on Friday. V6 said she forgot to ask the day nurse on Saturday to place the narcotic into the stat safe with her. V6 said she did not work Saturday at all, and she believes she worked the night shift Sunday October 27, 2024. V6 said the narcotic was still on top of the safe on Sunday October 27, 2024. V6 said she received a call from V3, ADON, around 10:00 AM asking where the Norco was because it was missing. V6 said if a medication is for the stat safe, then it should go into the stat safe right away. V6 said she had forgotten about the Norco after Friday. V6 said the other nurses, Did not offer to put the medication in the stat safe with me. On November 12, 2024 at 10:29 AM, V8, RN, said she saw the Norco narcotics setting on top of the stat safe. V8 said V6 came into the facility to receive report from V8. V8 told V6 the narcotic needed to be placed into the stat safe right away, and V6 asked V8 to wait until after nurse to nurse report. V8 said after V8 and V6 were done giving report, V8 said she forgot about the Norco, and then went home. On November 12, 2024 at 10:43 AM, V7, LPN, said the narcotic Norco came into the facility on a Friday evening (October 25, 2024). V7 said V5 gave the narcotic to V6. V7 said V6 did not drop the narcotic in the stat safe. V7 said V6 set the narcotic on top of the stat safe. V7 said he was working the night shift Sunday into Monday (October 28, 2024). V7 said he went into the medication room to find steri strips for his resident that had fallen. V7 said he went into the medication room at about 4:30 AM on October 28, 2024. V7 said he saw a card of medications on top of the stat safe at that time. V7 said that narcotic medication should be dropped into the stat safe right away. The facility's Stat Safe Delivery-Nursing policy, dated September 21, 2024 shows, All narcotics will be reconciled against the manifest at the time of delivery. The nurse should immediately take the stat safe deliver to the machine to restock. For narcotics, a witness should be present as these are added to the machine. Prior to the survey date of November 12, 2024, the facility had taken the following actions to correct the noncompliance: 1. A QAPI meeting was held on November 5, 2024 2. Current licensed associates were re-educated by the Director of Nursing or designee on controlled substance procedure for the STAT safe, controlled substance policy, controlled substance destruction policy, and proper documentation of controlled substances. 3. The Director of Nursing or designee will review the controlled substance documentation of 10 residents per week to verify compliance with appropriate practice per policy and nursing standards of practice. 4. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent.
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