cms_GA: 1496
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1496 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2018-09-28 | 759 | E | 1 | 1 | T04T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation of the medication pass and staff interviews, the facility failed to ensure that it was free of a medication error rate greater than five percent by not ensuring medications were given as ordered by physicians. Two of three nurses on two of five halls had medication errors, resulting in 11.54% medication error rate. There were three errors made out of twenty-six opportunities resulting in a 11.54% medication error rate. Affected was two out of six sampled residents R (R#55, R#114). The sample size was 60 residents. Findings include: Observation of medication administration on 9/25/18 at 8:21 a.m. on Magnolia Way, cart B, with Registered Nurse (RN) LL revealed she administered multiple medications to R#55. The following observations were made: [MEDICATION NAME] (a medication used to treat Asthma) 50 micrograms (mcg) one (1) spray each nostril and Vitamin C (a medication given as a supplement) 500 milligrams (mg) tablet was administered. During reconciliation with review of the (MONTH) (YEAR) physician's orders [REDACTED]. Registered Nurse (RN) LL failed to have resident rinse her mouth after inhalation of [MEDICATION NAME] and also administered only one Vitamin C 500 mg tablet instead of two tablets as ordered. Interview on 9/25/18 at 10:30 a.m. with RN LL stated she overlooked the order to give two Vitamin C tablets. She further stated the [MEDICATION NAME] order had been rewritten and the follow-up to rinse after use was not carried over, so she didn't see the directions to have resident rinse after use. Observation of medication administration on 9/26/18 at 8:39 a.m. on Branches, cart D, with Licensed Practical Nurse (LPN) MM revealed she administered multiple medications to R#114. The following observations were made: [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) 750 milligrams (mg) was administered. During reconciliation with review of the (MONTH) (YEAR) physician's orders [REDACTED]. Licensed Practical Nurse (LPN) MM administered only one [MEDICATION NAME] 750 mg tablet instead of two as ordered. Interview on 9/26/18 at 11:33 a.m. with LPN MM verified that she only gave one (1) [MEDICATION NAME] tablet, when order reads for [MEDICATION NAME] 750 mg give two tablets every morning. She stated she does not know how she overlooked the two tablet order on the Medication Administration Record [REDACTED] | 2020-09-01 |