| 115 |
AZALEA HEALTH AND REHABILITATION CENTER |
115044 |
1600 ANTHONY ROAD |
AUGUSTA |
GA |
30907 |
2018-09-20 |
758 |
D |
1 |
1 |
UFSE11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews and review of Resident # 36's medical record, the facility failed to ensure that an anti-anxiety medication was not administered past 14 days, as needed (PRN) without a rationale and without an end date, for one resident (R#36). The sample size was 39 residents. Findings include: Review of R#36's medical clinical record revealed [DIAGNOSES REDACTED]. R#33 had a Brief Interview of Mental Status (BIMS) of 03 indicating severe cognitive impairment. Minimum Data Set (MDS) and Plan of Care (P[NAME]) revealed she had behavior problems. R#36 exhibited behaviors toward staff, hitting during care, shouting, kicking at staff, being verbally abusive to staff, pulling at tablecloth in dining room and pulling at other resident's food. Review of Physician order [REDACTED]. Review further revealed the initial order date was 7/14/17. Review of the clinical record revealed the consultant pharmacist made recommendations to the physician in April, May, July, and (MONTH) (YEAR): [MEDICATION NAME] had been ordered as needed (PRN) and had been ordered longer than 14 days without a rationale or stop date. Recommendation on 4/19/18: [MEDICATION NAME] 1 mg Q4h PRN, need rationale in medical record and indicate duration. Physician response to recommendation dated 7/13/18 was Will investigate. It was signed and dated on 8/20/18 but he did not make any change in the order and did not include a rationale or stop date. Response to the consultant pharmacist recommendation to physician dated 8/24/18, the physician response was Nurses report she still needs it. He signed and dated 9/4/18 but made no change to order and did not include a rationale or stop date for the medication. Review of the MAR for July, August, and (MONTH) (YEAR) revealed R#36 had been on [MEDICATION NAME] ([MEDICATION NAME]) PRN since (MONTH) 14, (YEAR). Further review revealed R#33 received [MEDICATION NAME] eight times in July, 12 times in August, and five times in September, thru 9/19/18. Interview on 9/20/18 at 4:50 p. m. with Registered nurse (RN) Unit Manager AA confirmed the order for [MEDICATION NAME] ([MEDICATION NAME]) 1mg by mouth every 4 hours as needed for agitation, the order was active and dated back to 7/14/17. Interview further verified the physician wrote will investigate on the Consultant Pharmacist Recommendation to Physician dated 7/13/18, signed and dated it on 8/20/18 but did not make any change in the order and did not include a rationale or stop date. Further verification with the RN Unit Manager revealed in the medical record on the Consultant Pharmacist Recommendation to Physician dated 8/24/18, the physician wrote Nurses report she still needs it, signed and dated 9/4/18 but made no change to order and did not include a rationale or stop date for the medication. Interview on 9/20/18 at 5:00 p. m. with the Director of Nursing (DON) revealed she was aware of the 14 day rule for PRN medications. She further verified R#36 had been ordered [MEDICATION NAME] ([MEDICATION NAME]), had been on it since 7/14/17 and it continued to be active. Interview also verified the Consultant Pharmacist Recommendation to Physician dated 7/13/18 and 8/24/18 regarding State & Federal guidelines for use of [MEDICATION NAME], limited to 14 days or provide a rationale in the medical record and indicate the duration for the PRN order, and the physician made no changes. Interview with the DON further revealed her expectation that the facility follows the regulation, and the medical director follows the regulation when writing medication orders. She was not able to provide me a policy. |
2020-09-01 |