cms_GA: 2681
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rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
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2681 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2017-09-21 | 329 | E | 0 | 1 | V4Q111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to document behavior monitoring indication of use, and graduated dose reduction (GDR) for three, Resident (R#20, R#108 and R#67) of five residents reviewed for receiving [MEDICAL CONDITION] medications related to behaviors exhibited in the facility. The sample size was 31 residents. Findings include: 1. On 9/20/17 review of the medical record for R#20 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order on the current monthly Physician's Orders sheet dated 9/1/17 is an order for [REDACTED].>1.[MEDICATION NAME] (a medication given for anxiety) two milligrams (mg) tablet every four hours as needed for agitation which was originally ordered by the physician on 3/9/15, 2. [MEDICATION NAME] two mg QHS (every night at bedtime) routine-hold if sleepy originally ordered 9/16/17, 3. quetiapine [MEDICATION NAME] 200 mg tablet by mouth twice daily in the AM (morning) and HS (bedtime) for [MEDICAL CONDITION] (a psychiatric medical condition) originally ordered 12/15/11. Additional physician's orders also dated 9/1/17 on the same form include: 4.behavior pattern: agitation, chart number of incidents every shift, 5. monitor for side effect: drooling, tongue thrust, shuffled gait, abnormal involuntary movement-chart (Y or N). On 9/20/17 review of the medical record current Medication Administration Record (MAR) for R#20 revealed the order for [MEDICATION NAME] two mg as needed (PRN) for agitation was administered every night from 9/1/17 through 9/15/17. The back of this MAR a place for documentation related to administration of an as needed medication. Documentation is noted daily at bedtime the nurses administered the medication for anxiety and not for agitation as ordered by the physician. There was no documentation in the medical record for R#20 of the symptoms she was experiencing to indicate she was having anxiety. There was also no documentation of non-pharmacological interventions attempted to alleviate R#20's anxiety prior to administration of an PRN medication ordered for agitation. Further review revealed the physician's order to monitor behaviors documented on the MAR indicated R#20 has had multiple episodes of behaviors since 9/1/17. There was no documentation in the medical record indicating what symptoms R#20 was exhibiting or what non-pharmacological interventions were attempted to alleviate those behaviors. The most recent nursing documentation was dated 8/26/17. Review of the medical record Consultant Pharmacist Communication to the Physician dated 5/2017 revealed it was the most recent recommendation for a dose reduction from the consultant pharmacist. The physician responded to the request to reduce the quetiapine [MEDICATION NAME] (medication) and placed a check mark in the box that states . (Pertains to Antidepressants and Mood Stabilizers) It is my medical opinion and judgement that ALL future dose reductions are clinically contraindicated due to the severity of [MEDICAL CONDITION].The current dose is felt to be the lowest effective dose, and a disruption in medical care is not in the best interest of my patient after considering the risks versus benefits of the existing treatment.I acknowledge and confirm that the continued use is in accordance with relevant current standards of practice (including off-label use if applicable). Continued review revealed [MEDICATION NAME] (antipsychotic medication) ordered for R#20 for her [MEDICAL CONDITION] was not classified as an antidepressant or mood stabilizer. The Consultant Pharmacist made the same recommendation for dose reduction for the quetiapine [MEDICATION NAME] dated 5/2016. The physician's response to the pharmacist was the exact same response which was a standardized text personalized only for the different [DIAGNOSES REDACTED].#20. There was no physician's note in the medical record of R#20 to indicate why a dose reduction was not attempted for the quetiapine [MEDICATION NAME] for her [MEDICAL CONDITION]. 2. Review of the medical record on 9/20/17 for R#108 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician's Orders dated 9/1/17 for the current month of (MONTH) (YEAR) revealed orders for: 1.[MEDICATION NAME] 0.25 mg tablet by mouth at 10am and 3pm scheduled and one table as needed for agitation daily, hold if sleeping or lethargic originally ordered 7/4/17, 2. [MEDICATION NAME] hcl five mg tablet by mouth twice daily originally ordered 4/19/17, 3. [MEDICATION NAME] sod dr 125mg take one tablet by mouth twice daily originally ordered 4/19/17, 4. [MEDICATION NAME] 15mg one capsule by mouth at bedtime, originally ordered 4/19/17, 5. [MEDICATION NAME] hbr 20mg tablet by mouth daily originally ordered 7/4/17, 6. [MEDICATION NAME] 2mg/ml injection-give 2mg intramuscularly every 2 hours as needed for agitation not relieved by [MEDICATION NAME] originally ordered 7/5/17. There was no physician's order to monitor behaviors or side effects of antipsychotic medications. Review of the medical record current MAR reveals all medications have been administered as ordered. There was no documentation on the MAR, in the nurses' notes for R#108 to indicate the staff had monitored R#108 for behaviors or side effects of the antipsychotic medications he received. Review of the medical record Consultant Pharmacist Communication to the Physician dated 8/2017 for R#108 revealed a recommendation to review the necessity for the [MEDICATION NAME] (sleep medication) 15mg. The physician checked the following standardized text which indicated his response: .An attempted dose reduction/discontinuation at this time would likely impair the resident's function or cause psychiatric instability by exacerbating sleep.However, dose reduction may be attempted at a later date based on resolution of target symptoms or the emergence of side effects.I acknowledge and confirm that the continued use is in accordance with relevant current standards of practice (including off-label use if applicable). The [MEDICATION NAME] has an indication of use for [MEDICAL CONDITION]. Dose reduction/discontinuation of [MEDICATION NAME] would not exacerbate sleep. Review of the medical record Progress Notes written by the physician and dated 8/19/17 for R#108 revealed agitation had improved with dose titration of [MEDICATION NAME] (depression medication) and scheduled dosing of [MEDICATION NAME]. The progress note did not address the recommendation to decrease the [MEDICATION NAME] or to indicate why it was not reduced as recommended. Review of the medical record for R#108, including the Face Sheet, the Physician's Orders, the Minimum Data Set (MDS) (a comprehensive resident assessment) revealed there was no indication R#108 had a [DIAGNOSES REDACTED]. On 9/20/17 an interview with the Medical Records Director (MRD) revealed she had done a search of thinned medical records for R#20 and R#108 and was unable to locate any further documentation regarding pharmacy recommendations, behavior monitoring, side effect monitoring, indications of use, and dose reduction. On 9/20/17 during an interview with the DON at 1:30 p.m., she confirmed the previously identified concerns for R#20 and R#108 regarding behavior monitoring, indications for use and dose reduction. She agreed the documentation was missing from the record of R#20 for types of behaviors monitored/observed, non-pharmacological interventions tried prior to administering as needed medication, reason why medication ordered for agitation was given for anxiety and the reason the MD denied dose reduction of an antipsychotic medication. She also agreed documentation was missing from the medical record for R#108 in behavior monitoring, side effect monitoring, indication of use for [MEDICATION NAME], and why the physician refused the dose reduction. 3. Review of the medical record for R#67 indicated [DIAGNOSES REDACTED]. Under the (Section N410) Medication indicated the resident received antianxiety and antidepressant medications seven out of the 7-day assessment period. Under the (Section D0200) Mood indicated a score of one and the only identified mood factor was tired. Under (Section E) Behavior R#67 had no behaviors documented at any categories. Review of the medical record Care Plan for R#67 dated 6/24/17 for .[MEDICAL CONDITION] medications risk for adverse drug reaction related to med therapy included the interventions to observe for side effects of dizziness, drowsiness, dry mouth, muscle tightness, rash, constipation and /or diarrhea.Assess for irregular heartbeat, palpations, and [MEDICAL CONDITION], .Observe for tardive dyskinesia, slow, rhythmical involuntary movements.Remain observant of mood and behavior patterns, observing ability to alter indicators with no harm resulting to resident or others. Review of the medical record MAR for R#67 for the July, August, and (MONTH) of (YEAR) revealed no evidence of documentation of resident assessment for the use of [MEDICATION NAME] 1mg (milligram) three x (times) a day. No record of any anxiety was exhibited. Review of medical record Nurse Progress Notes for the past nine months for R#67 found no evidence of assessment for signs and symptoms or side effects for the use of antianxiety medication [MEDICATION NAME] as ordered and stated in the care plan. No indication of any issue with anxiety was documented. Interview of R#67 on 09/18/2017 3:07 p.m., revealed no evidence of anxiety for the resident. The resident was resting on his bed and stated he pretty much does nothing except stay in his room. Observation of R#67 on 9/19/17 revealed the resident was up in hall walking with staff at 3:30 p.m. A second observation on 9/19/17 at 4:30 p.m., revealed the R#67 in his room lying on his bed with his eyes closed. Interview with Licensed Practical Nurse (LPN) BB on 9/19/17 at 5:05 p.m., verified no documentation of an assessment for the effect/s of the medication [MEDICATION NAME] or observation/s for side effects in relation to the use of [MEDICATION NAME] 1mg three x's a day was conducted by nursing. LPN BB verified the medication administration record (MAR) failed to show any documentation of any behaviors to indicate the use of the medication was necessary. Review of the medical record physician progress notes [REDACTED]. Review of notes for the past six months failed to include any description of anxiety or behaviors to indicate a reason for the use of [MEDICATION NAME] 1 mg 3 x's a day. Review of medical record Pharmacy Review documentation revealed on 5/2017 a recommendation of a dose reduction for [MEDICATION NAME]. The printed form included .I have listed all psychoactive medications for this patient that are currently due for an evaluation.Please address each medication by checking the response that applies. The box checked .Pertains to Antidepressants and mood stabilizers. is my medical opinion and judgement that all future dose reductions are clinically contraindicated due to the severity of anxiety.The current dose is felt to be the lowest effective dose, and a disruption in medical care is not in the best interest of my patient after considering the risks versus benefits of the existing treatment.I acknowledge and confirm that the continued use is in accordance with relevant current standards of practice. This was signed by the physician on 6/1/17. A request was made to call the Consulting Pharmacist for information of the last dose reduction for R#67 and the use of [MEDICATION NAME] 1mg. The call was placed by the DON on 9/19/17 at 1:45 p.m. and phone was put on speaker phone. The Consulting Pharmacist was asked when the last dose reduction was attempted for the [MEDICATION NAME] for R#67? The Consulting Pharmacist stated he did not know when the last attempt was made and if it was ever reduced. The date on the order of this dose was 6/19/16. The Consulting Pharmacist stated, All I can do is make the request. I cannot control how the physician responds. Interview with the DON on 9/19/17 at 2:00 p.m., revealed she stated, The physician for this resident is the Medical Director. A request was made to find any evidence of a dose reduction. No additional information was provided. Request for any evidence of behavior monitoring or assessment for effectiveness or adverse side effects was made. No information was provided. Review of the medical record with the DON verified no documentation was present in the medical record of R#67. Review of the facility policy Assessment of Psychoactive Medications dated 2005, revealed .patients who receive antipsychotic, sedative, hypnotic, antidepressant, or any other medications prescribed to modify behavior are evaluated to determine the effectiveness of the medication for the identified problems.Every effort is made to ensure that patients who use these medications receive the intended benefit for the medication and to minimize the unwanted effects of the medication. | 2020-09-01 |