| 57 |
HANDMAKER HOME FOR THE AGING |
35016 |
2221 NORTH ROSEMONT BOULEVARD |
TUCSON |
AZ |
85712 |
2017-10-19 |
154 |
E |
0 |
1 |
PP4811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure three residents and/or representatives (#94, #195 and #230) were informed of the risks and benefits of [MEDICAL CONDITION] medications, prior to administering. Findings include: -Resident #94 was admitted (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 1, (YEAR) included that the resident exhibited intrusive behaviors and was difficult to redirect related to [DIAGNOSES REDACTED]. Interventions included for medications to be administered as ordered by the provider. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 5, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. The MDS also included the resident received an anti-depressant. The physician's orders [REDACTED]. However, review of the clinical record revealed no evidence that the resident was informed of the risks and benefits of the Trazadone and the [MEDICATION NAME]. In an interview conducted with a Licensed Practical Nurse (LPN/staff #131) on (MONTH) 19, (YEAR) at 9:30 a.m., she stated that before a resident is administered [MEDICAL CONDITION] medications, the risks and benefits should be explained to the resident. Staff #131 stated that an informed consent which includes the risks and benefits of the medication should be signed by the resident or resident representative before administration. During an interview conducted on (MONTH) 19, (YEAR) at 12:11 p.m. with the Director of Nursing (DON/staff 64), she stated that she was unable to locate an informed consent for these medications for this resident. -Resident #195 was admitted on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated (MONTH) 3, (YEAR) revealed the resident had a BIMS score of 8, which indicated moderate cognitive impairment. A care plan dated (MONTH) 2, (YEAR) included the resident was at risk for side effects and adverse reactions due to the use of an antidepressant medication. An approach included to involve family in resident care. A physician's orders [REDACTED]. However, there was no clinical record documentation that the risks and benefits of Trazadone were discussed with the resident/resident representative, prior to administration. An interview was conducted with staff #64 on (MONTH) 19, (YEAR) at 8:24 a.m. She stated that she was unable to locate an informed consent for the Trazadone. -Resident #230 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 1, (YEAR) included the resident was at risk for side effects and adverse reactions due to the use of antidepressant medications. An approach included to involve the family in resident care. Review of the MDS assessment dated (MONTH) 8, (YEAR) revealed a BIMS score of 8, which indicated the resident had moderate cognitive impairment. The MDS also included the resident was administered antipsychotic and antidepressant medications. Further review of the clinical record revealed that a consent form was signed by the resident's family member dated (MONTH) 1, (YEAR). However, the consent form did not include the name of any medications or any information regarding the risks and benefits of the medications. An interview was conducted with a Licensed Practical Nurse (LPN/staff #128) on (MONTH) 19, (YEAR) at 9:16 a.m. She stated that prior to administering [MEDICAL CONDITION] medications, an informed consent containing the name of the medication and the risks and benefits of the medication needs to be signed by the resident/resident representative. An interview was conducted with staff #64 on (MONTH) 19, (YEAR) at 9:27 a.m. She stated that an informed consent containing the risks and benefits of the medication must be obtained prior to administering the medication. She stated that if a resident is unable to sign the informed consent, then the resident's responsible person would be contacted to obtain the informed consent. A policy regarding Antipsychotic Medication Use did not address the need to obtain informed consent for antipsychotic medications or of the need to inform residents/resident representative of the risks and benefits, prior to administration. |
2020-09-01 |