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ELIZABETHTOWN, KY – MEDICATIONS & NARCOTICS MISSING; NARCOTICS REPLACED WITH UNKNOWN MEDICATIONS; PATIENTS ADMINISTERED UNKNOWN NARCOTICS

ELIZABETHTOWN NURSING AND REHABILITATION CENTER

LOCATED: 1101 WOODLAND DRIVE, ELIZABETHTOWN, KY 42701

ELIZABETHTOWN NURSING AND REHABILITATION CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO ENSURE AN EFFECTIVE SYSTEM WAS IN PLACE TO IDENTIFY AND REPORT DIVERSION OF MEDICATIONS
LEVEL OF HARM – IMMEDIATE JEOPARDY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, record review and review of the facility’s policies, it was determined the facility failed to ensure an effective system was in place to identify and report diversion of medications for five (5) of nine (9) sampled residents (Residents #1, #2, #3, #5, #6) and two (2) of two (2) unsampled residents (Unsampled Residents A and B). The facility failed to identify and report misappropriation of resident property, and diversion of medications/narcotics when staff found tape on the back side of narcotic blister packs, and the narcotics ([MEDICATION NAME]/narcotic [MEDICATION NAME]) were replaced with other unidentified medications. In addition, staff borrowed [MEDICATION NAME] (anti-anxiety), [MEDICATION NAME] (anti-depressant), for other residents’ use, even though staff had been trained in June 2014 not to borrow medications. (Refer to F431) On 08/31/14, during shift change (7:00 PM – 7:00 AM) review of Resident #1’s narcotic blister packs revealed [MEDICATION NAME] (narcotic pain medication) tablets were missing, and/or the pack was opened with a small slit. The [MEDICATION NAME] tablets were replaced with tablets that were a different size and the pack was then taped back. Licensed Practical Nurse (LPN) #2 and LPN #6 recognized there was tape on the back side of the whole narcotic blister pack, but they failed to report this immediately to a supervisor. The staff made copies of the narcotic blister packs and gave them to the Director of Nursing (DON) under her office door. Review of Resident #1’s narcotic count sheet revealed they continued to administer six (6) doses of the unknown tablets, that were in the blister pack of [MEDICATION NAME] 15 milligrams (mg), for Resident #1. The DON revealed Resident #1’s [MEDICATION NAME] had been replaced with a different medication of which the resident was not ordered. On 09/05/14, LPN #3 and Registered Nurse (RN) #4 discovered Resident #1 received three (3) doses of [MEDICATION NAME], 15 mg, on 09/04/14 which was not Resident #1’s normal pattern for taking this medication. Review of LPN #3’s note provided to the DON revealed the resident’s normal pattern was one tablet at night time. It was also determined Resident #1 had eighteen (18) tablets available on one medication card (this card had tape on the back and the [MEDICATION NAME] had been replaced) yet RN #1 documented she removed doses from Resident #1’s untampered pack of [MEDICATION NAME]. Interview on 09/26/14 at 1:29 PM, with the DON, revealed she was not sure if someone had tampered with the [MEDICATION NAME] 1 mg, and the [MEDICATION NAME] 5 mg. The DON stated she was instructed by pharmacy on 09/09/14 to destroy these medications. However, these medications were not destroyed until 09/15/14, after Resident #5 had received three (3) doses of these medications on 09/10/14, 09/11/14 and 09/13/14. In addition, Resident #2 had two (2) [MEDICATION NAME], 2.5 mg, narcotic sheets and two blister packs. The second [MEDICATION NAME] 2.5 mg narcotic blister pack had paper tape behind more than half of the blisters. Resident #3’s physician order [REDACTED]. Review of the first narcotic sheet, dated 08/01/14, and a second narcotic sheet dated 08/06/14, revealed RN #1 removed three (3) narcotics on 08/03/14 at 10:00 AM, 12:00 PM and 2:00 PM. RN #1 documented this medication was removed from the blister pack every two (2) hours instead of every (4) hours as ordered. Resident #6 was ordered to receive [MEDICATION NAME], 50 mg, at night. Review of the Medication Administration Record (MAR) documentation revealed multiple missed doses or the medication was not available to administer. However, the pharmacy was sending the medication routinely.

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here or call our toll free hot line number: 1-800-645-5262

You can make a difference even if your loved one has already passed away.

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5 Responses to “ELIZABETHTOWN, KY – MEDICATIONS & NARCOTICS MISSING; NARCOTICS REPLACED WITH UNKNOWN MEDICATIONS; PATIENTS ADMINISTERED UNKNOWN NARCOTICS”

  1. Vivian Middleton says:

    What good does it do to report these things? I have reported two incidents from Henderson, Ky regarding my uncles stay in Medco Nursing Home(Now Henderson Rehab). He was taking a blood thinner and was nicked while he was shaved. After we investigated this incident, we learned he had been shaved in the morning. We arrived at 4PM and he was still actively bleeding from just below his ear. Blood had pulled and was running off the plastic pillow onto the bed linens. Then we were there 1 week later and he was found laying cross way on the bed with the same clothes he was wearing the day before. I looked at his water container and found it to be empty with a brown ring around the bottom. I complained to the DON and requested on several occasions to speak to the Administrator. Even left messages to her as she never returned my calls. After State came in, they found many deficiencies. However, nothing has changed. I asked one of the State Workers why they didn’t just shut them down. His reply was “We have no where else to put them”. This is so sad. We were fortunate enough to find another facility that took excellent care of him. He had developed contractures of both of his hands and had to begin therapy. He was a Private Pay Patient. And all they did at the other facility was steal his money. We could not find an Attorney who was willing to take the case. Stating “It is very difficult to win these cases”. So having said all of this, until there is REAL PUNISHMENT for what these facilities get cited for, there will be no change. I am a retired Nurse of 30+ yrs and can tell you that these facilities have been this way for as long as I can remember. So Sad.

  2. vicky says:

    You can’t win because this facilities are owned by many different corporations who make millions and then in return donate to politicians……..can’t find who solely owns them. GREED and SIN

  3. James Jackson says:

    I think it goes without saying that there needs to be a strict and random erug screening process in place at these facilities. I never thought that these sceduled narcotics were wo easily accessed by the employees. There should be an i.d. card med safe so that it is logged when said employee removes narcotics. Long story short, all of these negligent employees should be fired and red flagged so that they aren’t ever able to do this ever again if they become employed by another similar facilty.

  4. emily says:

    doesn’t surprise me at all…probably happens a lot more.they just happen to get caught….so sad!!

  5. the social worker says:

    As I read these message I am disguisted. How many of you have worked in nursing homes instead of complaining about your uncle did you help the overworked staff. Do y’all realize that 1 CNA has to care for 25-30 patients like a newborn? Do you realize the behavioral and psychotic symptoms that most patients in these facilities exhibit? How about the physical, verbal, and emotional abuse that staff endures in an 8- 16 hour shift? Yeah there are some really bad people out there that abuse these poor elderly folks whose families can not care for them but there are some really great people that care for them as well. Dont just assume you know whats going on. Vivan Middleton did you ask why your uncle was across the bed, maybe he put himself like that after fighting the staff who were trying to straighten him up, maybe his water pitcher was empty because he was flinging the full pitcher at staff or hitting his roommate with it. And just because he is private pay doesn’t mean anything. ALL patients are treated equally no matter the payer source!

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