Other·December 17, 2021

F755 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

F812 §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are— (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized Title 22 § 72313. Nursing Service-Administration of Medications and Treatments. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. § 72353. Pharmaceutical Service-General. (b) Dispensing, labeling, storage and administration of drugs and biologicals shall be in conformance with state and federal laws. On 9/24/2021 the State Survey Agency (SSA) made an unannounced visit to the facility to investigate a complaint about quality of care and nursing services. The facility failed to implement its pharmaceutical and clinical record policies and procedures, failed to follow nursing standard of practice, and failed to ensure licensed nurses did not willfully falsify Resident 1’s clinical record by: 1. Licensed Vocational Nurses 1, 2, and 3 (LVNs 1, 2, and 3) documenting in the Medication Administration Record (MAR, - flowsheet to record all medications given to a resident) the intravenous (IV, - administered through a vein) administration of the medication Ertapenem (an antibiotic [used to treat infections]) given by Registered Nurse 1 (RN 1). LVNs scope of practice does not allow LVNs to administer IV antibiotics. 2. RN 1 not documenting administering Resident 1 Ertapenem IV from 9/3/2021 to 9/15/2021. As a result, Resident 1’s clinical record reflected inaccurate and false information of medication give and placed Resident 1 at risk for unsafe medication administration, medication errors, unmonitored side effects, and complications. A review of Resident 1's Admission Record indicated the facility originally admitted the resident on 7/13/2020 with a recent readmission date of 9/2/2021. Resident 1’s diagnoses included sepsis (the body's extreme response to an infection), urinary tract infection (UTI - bladder infection), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS, - a standardized assessment and care-screening tool) dated 7/28/2021, indicated the resident was alert, able to verbalize needs, and needed extensive assistance with one-person physical assist with bed mobility, dressing and toilet use. A review of the Physician’s Order for Resident 1 dated 8/31/2021, indicated to administer IV Ertapenem one gram daily for 14 days to treat UTI. A review of Resident 1's MAR for 9/2021 indicated: - On 9/3/2021, 9/4/2021, 9/9/2021, 9/10/2021, and 9/11/2021, LVN 1 administered Resident 1 the prescribed IV dose of Ertapenem. LVN 1 signed (with LVN 1’s name initials) the MAR falsely reflecting the administration of the IV medication to Resident 1. - On 9/6/2021, 9/12/2021, and 9/13/2021, LVN 2 administered Resident 1 the prescribed IV dose of Ertapenem. LVN 2 signed (with LVN 2’s name initials) the MAR falsely reflecting the administration of the IV medication to Resident 1. - On 9/15/2021, LVN 3 administered Resident 1 the prescribed IV dose of Ertapenem. LVN 3 signed (with LVN 3’s name initials) the MAR falsely reflecting the administration of the IV medication to Resident 1. On 9/24/2021 at 11:30 a.m. during an interview with LVN 3 and concurrent review of Resident 1’s 9/2021 MAR, LVN 3 stated he did not administer Ertapenem on 9/15/2021 as documented in the MAR. LVN 3 explained he documented giving Resident 1 the IV medication on behalf of RN 1, who was the staff that administered the IV to Resident 1. LVN 3 stated he was aware he should not have documented a medication he did not give. On 9/24/2021 at 11:37 a.m. during an interview with LVN 1 and concurrent review of Resident 1’s 9/2021 MAR, LVN 1 stated she did not administer Ertapenem on documented 9/3/2021, 9/4/2021, 9/9/2021, 9/10/2021, and 9/ 11/2021 as she documented. LVN 1 stated she documented the medication being given on behalf of RN 1, who was the staff that administered IV to Resident 1. LVN 1 stated she was aware she should not have documented a medication she did not give. On 9/24/2021 at 11:45 a.m. during an interview with Director of Nursing (DON) and a concurrent review of Resident 1's 9/2021 MAR, DON stated the nurse administering the medication should be the one documenting in the MAR. DON stated LVNs were not allowed to give IV medications as it was not within their scope of practice. On 11/18/2021 at 12:40 p.m. during a telephone interview, RN 1 stated she did not document in the MAR Resident 1’s administration of the IV antibiotic Ertapenem because she did not have access to the MAR. RN 1 stated she documented the administration of the antibiotic Ertapenem to Resident 1 in the nursing progress notes. RN 1 stated she was not informed she was responsible for signing Resident 1's MAR after administering Ertapenem. On 11/18/2021 at 1:08 p.m. during an interview, DON stated since RN 1 was able to document in Resident 1’s nursing progress note, she did have access to the MAR. A review of facility's policy and procedure titled, "Safe Medication Administration Practices, Long Term Care" revised on 11/19/2020, indicated to promote a culture of safety and prevent medication errors, nurses must adhere to the "rights of medication administration." Identify the right resident by using at least two resident identifiers, select the right medication, give the right dose, give the medication at the right time, give the medication by the right route, and provide the right documentation. A review of facility's policy and procedure titled "Medication Administration, General Guidelines" dated 4/2008, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. It also indicated that the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. The facility failed to implement its pharmaceutical and clinical record policies and procedures, failed to follow nursing standard of practice, and failed to ensure licensed nurses did not willfully falsify Resident 1’s clinical record by: 1. Licensed Vocational Nurses 1, 2, and 3 (LVNs 1, 2, and 3) documenting in the Medication Administration Record (MAR, - flowsheet to record all medications given to a resident) the intravenous (IV, - administered through a vein) administration of the medication Ertapenem (an antibiotic [used to treat infections]) given by Registered Nurse 1 (RN 1). LVNs scope of practice does not allow LVNs to administer IV antibiotics. 2. RN 1 not documenting administering Resident 1 Ertapenem IV from 9/3/2021 to 9/15/2021. As a result, Resident 1’s clinical record reflected inaccurate and false information of medication give and placed Resident 1 at risk for unsafe medication administration, medication errors, unmonitored side effects, and complications. The above violations jointly or separately had a direct or immediate relationship to the health, safety, or security of Resident 1.