Brookdale Monroe Square 1

The facility failed to ensure that one of three sampled medication aides had passed the required medication aide test for adult care homes within 60 days of their skills validation. Specifically, Staff B was observed administering medications despite having no record of passing the appropriate adult care home exam.

The facility failed to ensure medications were stored securely when a medication cart was left unlocked and unattended. During an observation, multiple residents passed by or sat near the unlocked cart, which contained various items including insulin pen needles and eye drops. The medication aide admitted to being distracted and forgetting to lock the cart while assisting with breakfast.

The facility failed to ensure medications were stored securely when a medication aide left a medication cart unlocked and unattended. During observations, residents passed by the unlocked cart, which contained various items including insulin pen needles, oral medications, and topical medications.

The facility failed to administer medications as ordered for several residents, including errors with diuretics and insulin. Specifically, a resident did not receive their prescribed Furosemide during the morning medication pass because the medication was unavailable on the cart, despite being documented as administered.

The facility failed to administer medications as ordered for several residents, including errors with a diuretic and rapid-acting insulin. Specifically, a resident did not receive Furosemide because the medication was unavailable on the cart, despite being documented as administered in the eMAR.

The facility failed to ensure medications were administered according to a licensed prescribing practitioner's orders. Specifically, a resident was being administered 100 mg of Colace twice daily when the practitioner intended for the dose to be administered only once daily.

The facility failed to ensure medications were administered as ordered by a licensed prescribing practitioner. Specifically, a resident was receiving a 100 mg dose of Colace twice daily when the practitioner intended for the medication to be administered only once daily.

The facility failed to record medications on the medication administration records (MAR) immediately following administration. During a morning medication pass, one resident was observed where the administration was not recorded immediately.

The facility failed to ensure physician notification for a resident's refusal of dental paste. Records showed the resident refused the prescribed medication daily from December 2015 through February 2016 without evidence of follow-up with the prescriber.