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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.163(a) | Meta fiber wafer, take one wafer with 8 ounces of water or juice daily is prescribed to Individual #1. Meta fiber wafer, take two wafers with 8 ounces of water or juice daily is prescribed to Individual #2. Meta fiber wafer container for Individual #2 was Individual #1's medication box and there was not meta fiber wafer container for Individual #1. Individual #1 was administered the Meta fiber wafer from 12/1/16 to 12/20/16. | Prescription medications shall only be used by the individual for whom the medication was prescribed. | CORRECTION PLAN for SIN # 00106724
All staff will continue to receive medication administration and documentation training upon induction and annually thereafter, including the required number of observations. Remediation training will continue if errors are made.
Additionally, we will review regulation 163 (a) in detail with direct care professionals, nurses, supervisors, managers and directors. In short, all personnel, who may implement and administer medications. In this particular situation, staff will be retrained that, a medication is only to be administered to the individual for whom it is prescribed.
It will be my, Petra Mussi¿s, responsibility to review the regulation with nurses, supervisors, managers and directors. It will be the supervisors, medication trainer and observers responsibilities to review the regulation with the direct care professionals assigned to them.
Additionally, we will remind the nightshift supervisors to remind and retrain the night shift staff to check all MARs against all blister packs for correctness nightly. When an error is detected, the medication supervisor needs to be consulted immediately for advice as to how to correct the situation. In this case, the Metamucil with the correct dosage should have been placed into each one of the indivisuals medication boxes. Should one of the medications not have been available, the pharmacy should have been contacted immediately for a refill in a timely fashion.
We have also assigned the nursing staff to compare all doctors¿ orders against MARs and blister pack labels within the next few weeks to ensure all medications are implemented correctly. This verification will continue every 6 month.
Finally, we have revised our medication error remediation process to focus on re-training in various ways, by various trainers without the previously associated disciplinary action. We hope this will decrease fear of making mistakes and increase new ways and methods of learning. We have also included various positive consequences for people who do not make errors for certain timeframes; these include commendations, various gifts, monetary amounts depending on years of no errors, and a congratulatory mention in the CCI employee up-dater for recognition by all.
This whole process will be completed by 3/24/2017. [Immediately and continuing at least quarterly, a designated staff person shall review all individuals current prescription medications, current MAR and current doctors orders to ensure all individuals have their prescription medications as prescribed and are being administered prescription medications for whom the medication is prescribed. (AS 2/23/17)] |
02/25/2017
| Implemented |
| 6400.164(a) | Risperidone 2mg, take 1/2 tablet orally twice daily (8AM/4PM) prescribed to Individual #3 was documented as being administered on 12/3/16 at 4:00PM by Direct Service Worker #2. Individual #3 was in the hospital emergency room on that date and at that time. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | CORRECTION PLAN for SIN # 00106724
All staff will continue to receive medication administration and documentation training upon induction and annually thereafter, including the required number of observations. Remediation training will continue if errors are made.
Additionally, we will review regulation 164 (a) in detail with direct care professionals, nurses, supervisors, managers and directors. In short, all personnel, who may implement and administer medications. In this particular situation, staff will be retrained that, when a person is in the hospital, an H is to be placed in the area where the staff¿s initials are typically written.
It will be my, Petra Mussi¿s, responsibility to review the regulation with nurses, supervisors, managers and directors. It will be the supervisors, medication trainer and observers responsibilities to review the regulation with the direct care professionals assigned to them.
Additionally, we will remind the nightshift supervisors to remind and retrain the night shift staff to check all MARs against all blister packs for correctness nightly. When an error is detected, the medication supervisor needs to be consulted immediately for advise as to correct the record. In this case, an H should have been placed and an incident report should have been written.
We have also assigned the nursing staff to compare all doctors¿ orders against MARs and blister pack labels within the next few weeks to ensure all medications are implemented correctly. This verification will continue every 6 month.
Finally, we have revised our medication error remediation process to focus on re-training in various ways, by various trainers without the previously associated disciplinary action. We hope this will decrease fear of making mistakes and increase new ways and methods of learning. We have also included various positive consequences for people who do not make errors for certain timeframes; these include commendations, various gifts, monetary amounts depending on years of no errors, and a congratulatory mention in the CCI employee up-dater for recognition by all.
This whole process will be completed by 3/24/2017. |
02/25/2017
| Implemented |
| 6400.164(b) | Dilantin 100 mg capsule, take 2 capsules (=200mg) orally 4:00PM prescribed to Individual #1 was not initialed as administered on 12/18/16. Silver Sulfadiazine u/f SSD, apply topically to buttock open areas twice daily as needed for skin breakdown prescribed to Individual #1 was initialed as administered 12/3/16 the corresponding name was not indicated. Lyrica 200 mg capsule, take one capsule orally twice daily prescribed to Individual #3 was initialed as administered at 8:00AM on 12/9/16. Direct Service Worker #1 documented that the medication was not administered. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | CORRECTION PLAN for SIN # 00106724
All staff will continue to receive medication administration and documentation training upon induction and annually thereafter, including the required number of observations. Remediation training will continue if errors are made.
Additionally, we will review regulation 164 (b) in detail with direct care professionals, nurses, supervisors, managers and directors. In short, all personnel, who may implement and administer medications. In this particular situation, staff will be retrained that, a medication administration is to be documented as soon as it is administered.
It will be my, Petra Mussi¿s, responsibility to review the regulation with nurses, supervisors, managers and directors. It will be the supervisors, medication trainer and observers responsibilities to review the regulation with the direct care professionals assigned to them.
Additionally, we will remind the nightshift supervisors to remind and retrain the night shift staff to check all MARs against all blister packs for correctness nightly. When an error is detected, the medication supervisor needs to be consulted immediately for advice as to how to correct the record. In this case, an EIM should have been filed and an incident report should have been written.
We have also assigned the nursing staff to compare all doctors¿ orders against MARs and blister pack labels within the next few weeks to ensure all medications are implemented correctly. This verification will continue every 6 month.
Finally, we have revised our medication error remediation process to focus on re-training in various ways, by various trainers without the previously associated disciplinary action. We hope this will decrease fear of making mistakes and increase new ways and methods of learning. We have also included various positive consequences for people who do not make errors for certain timeframes; these include commendations, various gifts, monetary amounts depending on years of no errors, and a congratulatory mention in the CCI employee up-dater for recognition by all.
This whole process will be completed by 3/24/2017. |
02/25/2017
| Implemented |
| 6400.167(b) | Phenytoin SOD 100mg Dilantin, take one capsule orally every morning and Citalopram 40mg, take one tablet orally every morning prescribed to Individual #3 were documented as administered on 12/4/16. The medications remained in the medication blister pack card for 12/4/16.
| Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | CORRECTION PLAN for SIN # 00106724
All staff will continue to receive medication administration and documentation training upon induction and annually thereafter, including the required number of observations. Remediation training will continue if errors are made.
Additionally, we will review regulation 167 (b) in detail with direct care professionals, nurses, supervisors, managers and directors. In short, all personnel, who may implement and administer medications. Staff will be reminded to follow the medication administration process as they were taught. The correct medication is to be administered at the correct time and if an error is made, the medication supervisor is to be notified as soon as the error is detected. An EIM must be filed if the medication is not given as prescribed nor within the 1 hour window.
It will be my, Petra Mussi¿s, responsibility to review the regulation with nurses, supervisors, managers and directors. It will be the supervisors, medication trainer and observers responsibilities to review the regulation with the direct care professionals assigned to them.
Additionally, we will remind the nightshift supervisors to remind and retrain the night shift staff to check all MARs against all blister packs for correctness nightly. If an error is found, i.e. a medication is still in a blister, which should be empty, the medication supervisor is to be notified as soon as the error is detected. An EIM must be filed if the medication is not given as prescribed nor within the 1 hour window.
We have also assigned the nursing staff to compare all doctors¿ orders against MARs and blister pack labels within the next few weeks to ensure all medications are implemented correctly. This verification will continue every 6 month.
Finally, we have revised our medication error remediation process to focus on re-training in various ways, by various trainers without the previously associated disciplinary action. We hope this will decrease fear of making mistakes and increase new ways and methods of learning. We have also included various positive consequences for people who do not make errors for certain timeframes; these include commendations, various gifts, monetary amounts depending on years of no errors, and a congratulatory mention in the CCI employee up-dater for recognition by all.
This whole process will be completed by 3/24/2017. |
02/25/2017
| Implemented |
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