NEWNAN,GA-NEWNAN HEALTH & REHABILITATION

SUMMARY STATEMENT OF DEFICIENCIES

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on record review, staff interviews, and review of the facility policy titled, Pharmacy
Services-Medication Administration-General, the facility failed to ensure that medications were obtained from the pharmacy in a timely manner for one of 10 sampled residents (R) (R#2). Specifically, medication for R#3 was obtained from the medication cart on another resident unit and given to R#2.

Findings include:
Review of the facility policy titled, Pharmacy Services-Medication Administration-General revealed: Borrowed Medications: Medications supplied for one patient are not to be administered to another patient.

Interview on 8/11/2023 at 12:08 p.m. with the Administrator and the Director of Nursing (DON) revealed on 5/28/2023 R#2 had an order for morphine sulfate. The medication had not arrived from the pharmacy. R#2 was complaining of a headache, so the hospice nurse, Registered Nurse (RN) II, administered R#3’s morphine sulfate to R#2. Licensed Practical Nurse (LPN) DD joined the conversation and stated she received a call from the facility charge nurse, RN GG, who was overseeing the care of R#2. LPN DD stated she was informed that the Hospice nurse, RN II, went to another unit and obtained a dose of morphine sulfate from R#3’s medication and gave the dose of medication to R#2.

Interview on 8/16/2023 at 4:09 p.m. with RN II revealed R#2 had an order for morphine sulfate (milligrams (MG) not given). RN II reported the charge nurse on duty at the facility was not able to retrieve the morphine sulfate from the facility’s automated medication dispensing machine.

Interview on 8/16/2023 at 4:17 p.m. with RN JJ, she reported she received a call from RN II on 5/28/2023 indicating R#2s morphine sulfate had not been delivered by the pharmacy to the facility. RN JJ reported R#2 was admitted to Hospice service on 5/17/2023. RN JJ indicated that on 5/18/2023, Hospice put in the order that went over to the pharmacy for R#2’s morphine sulfate. RN JJ also indicated it was not standard practice to use medication from another resident, but R#2 was in severe pain. RN JJ reported the morphine sulfate was listed on R#2’s Medication Administration Record (MAR) and indicated LPN FF had to give RN II the morphine sulfate from the narcotic box, signed it out, and RN II administered the morphine sulfate to R#2.

Interview on 8/16/2023 at 5:03 p.m. with LPN FF revealed RN II came from Unit 3 to Unit 2 and asked LPN FF for the morphine sulfate from R#3’s medication in the medication cart. LPN FF reported that RN II indicated RN JJ said it was ok to do so. LPN FF reported she gave the morphine sulfate to RN II because RN II indicated she knew there was another bottle of morphine sulfate in the medication cart, and it was for R#3. LPN FF reported the morphine sulfate was listed on the MAR for R#3, although she had not needed it for R#3.

Interview on 8/16/2023 at 5:22 p.m. with the DON revealed the morphine sulphate prescribed for R#2 had not been delivered to the facility before R#2 requested it on 5/28/2023. The DON reported when medications come into the facility, the Unit Managers on the 3:00 p.m. to 11:00 p.m. shift must confirm that each resident’s medication has arrived, then place the medications in the medication room. The DON reported R#2 was admitted to hospice on 5/17/2023, and the incident happened on 5/28/2023.

Interview on 8/16/2023 at 6:15 p.m. with Nurse Supervisor LPN DD revealed it was not standard practice for a nurse to remove medication from R#3’s medication to administer to R#2. LPN DD reported RN II signed out the morphine sulfate for R#3 and put R#2’s name on it.