Jefferson Healthcare Center

Review of facility's Quality Assurance (QA) program revealed, in part, a Quality Assurance Performance Improvement (QAPI) plan created on 03/25/2025 which identified a problem with medication cart audit reports.

Further review revealed a corrective action plan that included an initial audit would be performed on all medication carts by administrative nurses and weekly audits would be performed to ensure all required nurse signatures were documented.

Further review revealed documentation on 04/01/2025, the narcotic book weekly audit was documented as a recurring problem with an intervention to discipline staff for noncompliance.

In an interview on 05/01/2025 at 11:08AM, S2Director of Nursing (DON) confirmed the facility opened the QAPI for medication cart audits which included the narcotic book audits on 03/25/2025. S2DON further confirmed during the current survey, the survey team identified the narcotic reconciliation documentation which was missing nurse signatures and they were inaccurate. S2DON indicated that no disciplinary actions of nursing staff were performed regarding the recurring problems identified in the narcotic book audits. S2DON further indicated continued problems in the above area would indicate the facility's QA/QAPI process had been ineffective and had not been revised.

195272

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 195272 B.

Wing 05/01/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Jefferson Healthcare Center 2200 Jefferson Hwy Jefferson, LA 70121