Federal inspectors found these medication safety violations during an August inspection at Ararat Nursing Facility on Mission Hills Road, along with nurses who failed to properly document controlled substances and missing signatures on drug accountability logs.
Resident 177, who has low sodium levels and seasonal allergies, told inspectors on August 5 that she uses saline spray "as needed to help her breathe." The spray bottle sat on her bedside table. When she returned from a hospital stay, she brought the saline spray back to the facility with her.
But the facility's order summary showed no prescription for the nasal spray. Licensed Vocational Nurse 1 confirmed on August 8 that without physician orders, "the facility cannot administer medications." The nurse said doctors should be aware of any diagnosis and condition to prescribe appropriate medications.
The Director of Nursing told inspectors that residents cannot receive medications without physician orders. "Without a physician's order the facility would not be able to give resident's their medication and would not be able to provide care for the residents," she said.
Self-Medication Assessment Never Done
Resident 227 presented a different problem. The alert, cognitively intact man with glaucoma was observed taking Areds 2 eye vitamins from a bottle at his bedside on August 6. He had no prescription for the supplement.
During a June care team meeting, staff documented that the resident "knows his vitamins and supplements, wanted to keep his medications at the bedside." But they never assessed whether he could safely self-administer medications.
The facility's Minimum Data Set Coordinator admitted they "failed to assess the resident for self-administration of medications" despite his expressed desire to manage his own supplements. No medication self-administration assessment was completed when he was admitted.
"It was important to assess the resident for their ability to self-administer their medications to honor the resident's rights," the coordinator said. After assessment, staff should obtain a physician's order for self-administration "to ensure safe use."
Licensed Vocational Nurse 3 said she didn't know how the Areds 2 bottle ended up at the resident's bedside, suggesting "it must be the family member that gave the medication."
The Director of Nursing called the resident "a researcher" who was "alert and oriented very much capable of taking his own medications." But she acknowledged that failing to do a proper assessment "deprived the resident of his right to self-determination." The lack of an order for Areds 2 "had predisposed the resident to taking unnecessary medications and the adverse effect of the medication that can cause harm."
Missing Controlled Substances
Inspectors discovered more serious problems with controlled medication tracking on August 5. During an observation of the medication cart, they found discrepancies between accountability logs and actual pill counts for two powerful medications.
One dose of clonazepam, an anxiety medication, was missing from Resident 25's bubble pack. The controlled drug record showed 11 tablets should remain after the last documented dose on August 4, but only 10 tablets were in the package.
Similarly, one dose of diphenoxylate with atropine, an anti-diarrheal medication, was missing from Resident 30's supply. The log indicated 10 tablets should remain after the last recorded dose on August 1, but only nine were found.
Licensed Vocational Nurse 7 admitted administering both medications that morning at 9 AM but "forgot to sign the Controlled Drug Record accountability logs." The nurse acknowledged failing to follow facility policy requiring immediate documentation after preparing each controlled substance dose.
"If documentation was not accurate then it can lead to medication error if overdosed leading to stoppage of breathing, hospitalization and possibly death," the nurse told inspectors.
Widespread Documentation Failures
The problems extended beyond individual nurses. During a record review on August 6, the Director of Nursing couldn't locate verifying signatures on four controlled drug accountability logs and nine drug destruction logs for discontinued medications.
The Director of Nursing said there was "no consistent process to sign the logs" when controlled medications were received or transferred. Similarly, nurses weren't consistently signing drug destruction logs when disposing of unused medications.
"The DON needed to immediately implement a process for including verifying signatures," inspectors documented. The Director of Nursing acknowledged the importance of controlled medication accountability "to ensure each dose was accounted for until disposed" and "to prevent medication diversions and accidental exposure of harmful substances to residents."
Policy Violations
The facility's own policies required complete medication orders including drug name, dosage, frequency, duration, route, and the condition being treated. All orders must be transcribed onto appropriate administration records.
For self-administered medications, policy required assessment during admission for residents who request to manage their own drugs. The interdisciplinary team should evaluate whether self-administration is "safe and appropriate" before obtaining physician orders.
Controlled substance policies mandated that nurses "immediately" document each dose on accountability records when medications are removed from supplies. Physical inventories should occur at each shift change with two licensed nurses documenting the count.
The facility's medication error policy specifically identified administration of unprescribed medications as a violation.
Residents at Risk
Resident 25, admitted with anxiety, was prescribed clonazepam twice daily as needed for agitation and constant pacing. The missing dose documentation created accountability gaps for a medication that can cause severe respiratory depression.
Resident 30, with functional diarrhea, received diphenoxylate with atropine three times daily. The anti-diarrheal medication contains controlled substances requiring strict tracking.
Both residents remained at risk for medication errors due to inadequate documentation systems that could lead to overdoses or missed doses.
The inspection findings revealed a facility where residents took unprescribed medications while staff lost track of controlled substances that could cause serious harm or death if misused. Despite having detailed policies, Ararat Nursing Facility failed to implement basic medication safety practices that protect vulnerable residents from preventable medication errors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Nursing Facility from 2024-08-09 including all violations, facility responses, and corrective action plans.