cms_GA: 4341
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4341 | PLEASANT VIEW NURSING CENTER | 115411 | 475 WASHINGTON STREET | METTER | GA | 30439 | 2016-11-23 | 309 | K | 1 | 0 | C00C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, it was determined the facility failed to administer medications and finger blood sugar levels (FSBS) as ordered by the physician for fifteen (15) residents (R10, 11, 12, 16, 18, 19, 20, 21, 22, 23, 27, 28, 29, 32 and 33), on 8/21/16 at 6:00 a.m. when there was no licensed nurse scheduled to the secured unit to administer medications or FSBS. Insulin as ordered and for one resident (R7) and for medications to administered timely and not past the one hour window, allowed by Federal Regulation, on 8/20/16 at 9:00 p.m. for three residents (R17, 24 and 25). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. On (MONTH) 2, (YEAR) at 5:00 p.m., the previous Administrator and previous Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for nineteen (19) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. Findings include: Review of the facility Schedule Sheet for (MONTH) 31, (YEAR) to (MONTH) 3, (YEAR) revealed that LPN MM was scheduled to work on the secured unit, on 8/20/16 through 8/21/16 on the 7:00 p.m. to 7:00 a.m. shift. Interview on 10/18/16 at 2:20 p.m. with LPN MM revealed that she worked as a nurse at Pleasant View and another facility in a neighboring town, during the same twelve hour shift, and did not administer the 6:00 a.m. on medications or obtain the FSBS on 8/21/16. Continued interview revealed that on 8/20/16 she was working at another facility in a neighboring city, she stated that she arrived at Pleasant View at approximately 10:45 p.m. and then passed out all of the 9:00 p.m. She stated that she left Pleasant View around 12:00 a.m. to return to her other job at the second facility. Further interview revealed that LPN MM did not return to Pleasant View to administer morning medications to the residents on 8/21/16. LPN MM stated when she left Pleasant View there was not a nurse to relieve her and she left the secured unit unsupervised. Which was confirmed through review of actual time sheets (punch sheets) at both facilities. (Cross refer to F224 and F514) 1. R7 had a [DIAGNOSES REDACTED]. However, a review of the clinical record, including the MARs was withheld by licensed nursing staff for various blood sugar parameters. The insulin was not administered as ordered for R7 on the following dates: in (MONTH) (YEAR): On 6/17/16 at 6:30 a.m., on 6/23/16 at 6:30 a.m., and on 6/24/16 at 6:30 a.m., the insulin was not administered but without an explanation. July (YEAR): On 7/8/16 at 9 p.m., the insulin was withheld for a blood sugar level of 114 for R7. On 7/9/16 the insulin was withheld at 6:30 a.m. for a blood sugar level of 129 and at 9 p.m. for a blood sugar level of 79. On 7/10/16 at 6:30 a.m., the insulin was withheld for a blood sugar level of 101. On 7/28/16 at 6:30 a.m., the insulin was withheld for a blood sugar level of 88. September (YEAR): On 9/16/16 at 6:30 a.m. the insulin was withheld for an initial blood sugar of 31 and a follow up blood sugar of 120 for R7. October (YEAR): On 10/7/16 at 9 p.m., the insulin was not administered but without an explanation for R7. Record review of the (MONTH) (YEAR) MAR reveals no evidence that on 10/9/2016 at 6:30 a.m. and 4:30 p.m. of a blood sugar check or sliding scale insulin give. On the same day at 9:00 p.m. the blood sugar was 399 with [MEDICATION NAME] R 10U given. Review of the Transfer Form (hospital transfer) dated 10/10/2016 at 12:00 a.m. the blood sugar was 484 with increased behaviors for R7. Review of a nurses note entry of 10/9/16 at 11:55 p.m. revealed that R7 sustained an injury due to hitting the doorframe of her room and was transferred to the hospital. Review of the hospital admission records on 10/10/16 revealed the resident was transferred from a smaller local hospital to a higher acuity of care hospital. The resident had multiple admitting [DIAGNOSES REDACTED]. The serum blood sugar on 10/10/16 at 5:21 a.m. was 567 (normal is 65-110) for R7. The trauma chief resident notes on 10/10/16 at 5:24 a.m. revealed the resident had profound acidosis, patient on DKA (Diabetic Ketoacidosis) protocol including intravenous bolus Insulin. An interview with the previous Director of Nursing (DON) on 10/25/2016 at 5:30 p.m. revealed that she could not explain why the resident's Insulin was held or why the Physician was not notified. She revealed that she was not aware of the policy for contacting the Physician for abnormal FSBS. 2. R11 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. However, review of the (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MARs) for R11 revealed that no evidence that the 35 units of [MEDICATION NAME] Insulin was administered daily at 7:00 a.m. three (3) times in (MONTH) (YEAR) (8/1/16, 8/21/16, 8/23/16) and three (3) times in (MONTH) (YEAR) (10/4/16, 10/13/16 and 10/20/16). Continued review of the MARs revealed that there was no evidence that the FSBS as care planned ten (10) times in (MONTH) (YEAR) (8/20/16 at 9:00 p.m., on 8/21/16 at 6:00 a.m. when there was no LN available on the secured unit and 9:00 p.m., on 8/26/16 at 6:00 a.m. and 9:00 p.m., 8/26/16 at 6:00 a.m. and 9:00 p.m., 8/27/16 at 9:00 p.m., 8/28/16 at 6:00 a.m., on 8/29/16 at 9:00 p.m.) and six (6) times in (MONTH) (YEAR) (10/3/16 at 9:00 p.m., on 10/4/16 at 6:00 a.m., on 10/12/16 at 9:00 p.m., on 10/13/16 at 6:00 a.m., on 10/19/16 at 9:00 p.m. and on 10/20/16 at 6:00 a.m. Review of the medical record for R11 revealed that the resident was stable with no evidence of adverse reactions related to medications. Review of pertinent labs done 6/20/16 revealed that the HGBA1C was elevated at 7.6 (normal is 3. R12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED].) every day (scheduled at 6:30 a.m.); a physician's orders [REDACTED]. every day (scheduled at 6:30 a.m.); a physician's orders [REDACTED].=5 units; 301-400=10 units; 401-500=15 units; 501-550=18 units. However, review of the (MONTH) (YEAR) MAR revealed that licensed nursing staff failed to administer the [MEDICATION NAME] and [MEDICATION NAME] at 6:30 a.m. and failed obtain the FSBS at 6:30 a.m. as ordered on [DATE] for R12. However, review of the (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) MARs for R12 revealed no evidence that the 45 units of [MEDICATION NAME] was administered daily at 6:30 a.m. eleven (11) times in (MONTH) (YEAR) (8/9/16, 8/18/16, 8/21/16, 8/22/16, 8/23/16, 8/26/16, 8/27/16) and two (2) times in (MONTH) (YEAR) (10/15/16, and 10/20/16), on 8/21/16 there was no nurse at 6:30 a.m. to administer the medication. There was no evidence that the 30 units of [MEDICATION NAME] was administered at bedtime (9:00 p.m.) seven (7) times in (MONTH) (YEAR) (8/15/16, 8/17/16, 8/18/16, 8/20/16, 8/21/16, 8/22/16, 8/25/16) and one (1) time in (MONTH) (YEAR) (10/19/16). On 8/20/16 at 9:00 p.m. there was no nurse available to administer the medication. Continued review of the MARs for R12 revealed no evidence that FSBS were obtained twenty-two (22) times in (MONTH) (YEAR) (8/17/16 at 9:00 p.m., on 8/18/16 at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m., on 8/19/16 at 6:30 a.m., on 8/20/16 at 9:00 p.m., on 8/21/16 at 6:30 a.m. (on 8/20/16 at 7:00 p.m. through 8/21/16 at 7:00 a.m. there was no nurse assigned to the secured unit) and 9:00 p.m., on 8/22/16 at 6:30 a.m. and 9:00 p.m., on 8/23/16 at 6:30 a.m., on 8/25/16 at 9:00 p.m., on 8/26/16 at 6:30 a.m. and 9:00 p.m., on 8/27/16 at 11:30 a.m. and 9:00 p.m., on 8/28/16 at 6:30 a.m., on 8/29/16 at 11:30 a.m. and 4:30 p.m., on 8/31/16 at 11:30 a.m. and 4:30 p.m.); twelve (12) times in (MONTH) (YEAR) (9/1/16 at 9:00 p.m., on 9/2/16 at 11:30 a.m. and 9:00 p.m., on 9/3/16 at 9:00 p.m., on 9/11/16 at 11:30 a.m. and 4:30 p.m., on 9/19/16 at 11:30 a.m. and 4:30 p.m., on 9/28/16 at 11:30 a.m., 4:30 p.m. and 9:00 p.m., on 9/29/16 at 6:30 a.m.); and seven (7) times in (MONTH) (YEAR) (10/15/16 at 11:30 a.m. and 4:30 p.m., on 10/20/16 at 6:30 a.m., on 10/21/16 at 11:30 a.m. and 4:30 p.m. and on 10/22/16 at 11:30 a.m. and 4:30 p.m.). Furthermore, review of the MARs for R12 revealed no evidence that Insulin was administered per sliding scale three (3) times in (MONTH) (YEAR) and eight (8) times in (MONTH) (YEAR) for the following FSBS: In (MONTH) (YEAR): a. On 8/1/16 at 11:30 a.m. was 298. However, there was no evidence that the 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. b. On 8/1/16 at 4:30 p.m., the resident's FSBS was 312. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. c. On 8/31/16 at 9:00 p.m., the resident's FSBS was 402. However, there was no evidence that the 15 units of [MEDICATION NAME] R Insulin was administered per sliding scale. In (MONTH) (YEAR): d. On 9/2/16 at 6:30 a.m., the resident's FSBS was 227. However, there was no evidence that that 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. e. On 9/4/16 at 11:30 a.m. the resident's FSBS was 269. However, there was no evidence that the 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. f. On 9/6/16 at 9:00 p.m. was 303. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. h. On 9/7/16 at 6:30 a.m., the resident's FSBS was 291. However, there was no evidence that the 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. i. On 9/7/16 at 9:00 p.m., the resident's FSBS was 379. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. [NAME] On 9/11/16 at 9:00 p.m. the resident's FSBS was 332. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. k. On 9/23/16 at 6:30 a.m., the resident's FSBS was 259. However, there was no evidence that the 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. l. On 9/23/16 at 9:00 p.m., the resident's FSBS was 381. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. Review of the medical record for R12 revealed that the resident was stable with no evidence of adverse reactions related to medications. Review of pertinent labs done 4/6/16 revealed that the HGBA1C was abnormally high at 13.1 (normal is 4. R27 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. However, review of the (MONTH) (YEAR) MAR revealed that licensed nursing staff failed to obtain the FSBS at 6:30 a.m. as ordered on [DATE] (as there was no nurse assigned to the secured unit). Interview on 10/18/16 at 2:20 p.m. with LPN MM revealed she did not administer morning medications to the residents on 8/21/16. Review of the (MONTH) (YEAR) MAR revealed that there was no evidence that [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 100 mgs., [MEDICATION NAME] ER 250 mgs., [MEDICATION NAME] 200 mgs and [MEDICATION NAME] 30 units SQ was administered to R27 as scheduled at 9:00 p.m. on 8/20/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs for R27 revealed there was no evidence that the [MEDICATION NAME] was administered on 8/11/16, 8/20/16, 8/21/16, 8/22/16, 8/25/16, 8/26/16, 9/6/16, 9/7/16, 9/10/16, 9/11/16, 9/18/16, 10/3/16 and 10/12/16. There was no evidence that the FSBS were obtained on 8/21/16, 8/22/16, 8/26/16, 8/27/16, 8/28/16, 10/4/16, 10/13/16 and 10/20/16. Review of the medical record for R27 revealed no adverse reactions related to medications. The HGBA1C done 5/27/16 was within normal limits. 5. R28 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed physician's orders [REDACTED]. Three times a day (scheduled at 6:00 a.m., 2:00 p.m. and 10:00 p.m.) and to obtain FSBS every morning (scheduled at 6:30 a.m.). However, review of the (MONTH) (YEAR) MAR revealed that licensed nursing staff failed to administer the [MEDICATION NAME] at 6:30 a.m. and the [MEDICATION NAME] at 6:00 a.m. as ordered on [DATE]. Licensed nursing staff failed to obtain the FSBS at 6:30 a.m. as ordered on [DATE]. Interview on 10/18/16 at 2:20 p.m. with LPN MM revealed that she worked as a nurse at Pleasant View and another facility in a neighboring town and did not obtain the FSBS on 8/21/16. Review of the (MONTH) (YEAR) MAR revealed that there was no evidence of [MEDICATION NAME] 1000 mgs., [MEDICATION NAME] 1 mg., [MEDICATION NAME] 25 mgs., [MEDICATION NAME] 17 gms , [MEDICATION NAME] 20 mgs., [MEDICATION NAME] SR 150 mgs., and [MEDICATION NAME] 2 mgs to R28 being administered as scheduled at 9:00 p.m. on 8/20/16. Interview on 10/18/16 at 2:20 p.m. with LPN MM revealed that on 8/20/16 she was working at another facility in a neighboring city, she stated that she arrived at Pleasant View at approximately 10:45 p.m. and then passed out all of the 9:00 p.m. She stated that she left Pleasant View around 12:00 a.m. to return to her other job at the second facility. Review of the medical record for R28 revealed a physician's orders [REDACTED]. However, review of the MARs revealed there was no evidence that the FSBS on 8/8/16, 8/21/16, 8/22/16, 8/23/16, 8/28/16, 8/31/16 and 10/4/16. Although there was no evidence that the on the MARs that the resident refused FSBS on other days, there was no evidence that the FSBS were attempted on these dates. There was no adverse reactions related to medications for R28. 6. R29 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed physician's orders [REDACTED]. The resident also had a physician's orders [REDACTED]. However, review of the (MONTH) (YEAR) MAR revealed that licensed nursing staff failed to administer the [MEDICATION NAME] and [MEDICATION NAME] and failed to obtain the FSBS at 6:30 a.m. as ordered on [DATE]. Review of the (MONTH) (YEAR) MAR revealed that there was no evidence that [MEDICATION NAME] 80 mgs, Klonopin 1 mg, [MEDICATION NAME] 600 mgs, [MEDICATION NAME] 10 mgs and [MEDICATION NAME] 50 units SQ to R29 was administered as scheduled at 9:00 p.m. on 8/20/16. Review of the record for R29 revealed a physician's orders [REDACTED]. However, review of the MARs revealed there was no evidence that the [MEDICATION NAME] was administered on 8/1/16, 8/6/16, 8/24/16, 8/25/16, 8/26/16, 10/1/16, 10/2/16, 10/4/16, 10/12/16 and 10/13/16. Review of the record for R29 revealed a physician's orders [REDACTED]. However, review of the MARs revealed there was no evidence that the FSBS were obtained on 8/2/16, 8/7/16, 8/25/16, 8/26/16, 8/27/16, 10/3/16, 10/4/16, 10/13/16, 10/14/16 and 10/20/16. Review of the medical record for R29 revealed no evidence of an adverse reactions related to medications. The HGBA1C done 6/6/16 was high at 7 (normal is 7. R32 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR revealed that licensed nursing staff failed to administer the [MEDICATION NAME] 70/30 at 6:30 a.m. as ordered on [DATE]. Continued review of the (MONTH) (YEAR) MAR revealed that there was no evidence that [MEDICATION NAME] 200 mgs was administered to R32 as scheduled at 9:00 p.m. on 8/20/16. Review of the medical record revealed a physician's orders [REDACTED]. [REDACTED]. However, review of the MARs for R32 revealed there was no evidence that the 40 units of [MEDICATION NAME] 70/30 Insulin was administered at 6:30 a.m. two (2) times in (MONTH) (YEAR) (8/21/16, 8/22/16) and three times in (MONTH) (10/4/16, 10/13/16 and 10/20/16). There was no evidence that the 10 units of [MEDICATION NAME] 70/30 Insulin was administered as follows: (MONTH) (YEAR) on 8/21/16 at 6:30 a.m., on 8/22/16 at 6:30 a.m., 8/27/16 at 12 noon and 5:00 p.m. a total of four (4) times; in (MONTH) (YEAR) on 9/6/16 at 5:00 p.m., 9/28/16 at 5:00 p.m., a total of two (2) times; and in (MONTH) (YEAR) on 10/4/16 at 6:30 a.m., 12 noon and 5:00 p.m., 10/13/16 at 6:30 a.m., 10/14/16 at 12 noon and 5:00 p.m., 10/20/16 at 6:30 a.m. and on 10/21/16 at 12 noon and 5:00 p.m. a total of nine (9) times. Continued review revealed there was no evidence that the FSBS was obtained on 10/4/16. Review of the medical record for R32 revealed no adverse reactions related to medications. The HGBA1C done 6/23/16 was high at 8.1 (normal is 8. R33 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. The resident also had a physician's orders [REDACTED]. However, review of the (MONTH) (YEAR) MAR for R33 revealed that licensed nursing staff failed to administer the [MEDICATION NAME] at 6:30 a.m. and [MEDICATION NAME] Insulin at 7:00 a.m. and failed to obtain the FSBS at 6:30 a.m. as ordered on [DATE]. Review of the (MONTH) (YEAR) MAR revealed no evidence that [MEDICATION NAME] Insulin 60 units SQ was administered to R33 as scheduled at 9:00 p.m. on 8/20/16. Review of the medical record revealed for R33 a physician's orders [REDACTED]. However, review of the MARs revealed there was no evidence that the 12 units of [MEDICATION NAME] Insulin was administered seven (7) times in (MONTH) (YEAR) (8/21/16 at 7:00 a.m., 8/22/16 at 7:00 a.m., (see above notations related to 8/21/16 regarding no nurse available) 8/23/16 at 4:00 p.m., 8/25/16 at 4:00 p.m., 8/28/16 at 7:00 a.m., 8/29/16 at 12 noon and 8/30/16 at 12 noon), two (2) times in (MONTH) (YEAR) (9/26/16 at 12 noon and 4:00 p.m.) and two (2) times in (MONTH) (YEAR) (10/20/16 at 7:00 a.m. and 10/24/16 at 7:00 a.m.). There was no evidence that the 60 units of [MEDICATION NAME] Insulin was administered five (5) times in (MONTH) (YEAR) (8/20/16 at 9:00 p.m., 8/21/16 at 9:00 p.m., (see above notations related to 8/20/16 and 8/21/16, when no nurse was available to administer medications) 8/25/16 at 9:00 p.m., 8/26/16 at 9:00 p.m. and 8/28/16 at 9:00 p.m.) and six (6) times in (MONTH) (YEAR) (9/2/16 at 9:00 a.m., 9/7/16 at 9:00 p.m., 9/21/16 at 9:00 a.m., 9/27/16 at 9:00 p.m. and 9/30/16 at 9:00 a.m.). Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Further review revealed there was no evidence that the FSBS was obtained four (4) times in (MONTH) (YEAR) (8/21/16, 8/22/16, (see above notations related to 8/21/16, when no nurse was available to administer medications) 8/23/16 and 8/28/16). Review of the medical record for R33 revealed no evidence adverse reactions related to medications. The HGBA1C done 9/27/16 was high at 7.2 (normal is 9. R20 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R20 had a physician's orders [REDACTED]. However, review of the (MONTH) (YEAR) MAR revealed there was no evidence that the FSBS was obtained as ordered on [DATE] and 8/22/16 at 6:30 a.m., 8/26/16 at 6:30 a.m., 8/27/16 at 6:30 a.m. and 4:30 p.m., 8/28/16 at 6:30 a.m. There was a physician's orders [REDACTED]. However, review of the (MONTH) (YEAR) MAR revealed there was no evidence that the FSBS were obtained as ordered on [DATE] and 8/22/16 at 6:30 a.m., 8/26/16 at 6:30 a.m., 8/27/16 at 6:30 a.m. and 4:30 p.m., 8/28/16 at 6:30 a.m. 10. R16 had current [DIAGNOSES REDACTED]. R16 had a physician's orders [REDACTED]. However, a review of the (MONTH) (YEAR) MAR revealed there was no evidence that the FSBS was obtained on 8/22/16 and 8/26/16 as ordered by the physician. There was also a physician's orders [REDACTED]. However, review of the (MONTH) (YEAR), (MONTH) (YEAR) and the (MONTH) (YEAR) MARs revealed there was no evidence that the insulin was administered on 8/2/16, 8/3/16 and 8/4/16 at 4:00 p.m., on 8/9/16 at 7:00 a.m., on 8/13/16 at 4:00 p.m., 8/14/16 at 7:00 a.m. and 4:00 p.m., 8/16/16 at 4:00 p.m., 8/18/16 at 7:00 a.m. and 4:00 p.m., 8/20/16 at 4:00 p.m., 8/21/16, 8/22/16, 8/23/16 at 7:00 a.m. and 4:00 p.m., 8/24/16 at 4:00 p.m., 8/25/16 at 7:00 a.m. and 4:00 p.m., 8/27/16 and 8/28/16 at 7:00 a.m. and 4:00 p.m. and on 9/2/16 at 7:00 a.m., 9/6/16 at 4:00 p.m., 9/11/16 at 4:00 p.m., 9/14/16 at 7:00 a.m., 9/19/16 at 7:00 a.m. and 4:00 p.m., 9/26/16 at 7:00 a.m. and on 9/28/16 at 4:00 p.m. and on 10/4/16 at 7:00 a.m. and 4:00 p.m., 10/8/16, 10/9/16, 10/10/16, and 10/13/16 at 7:00 a.m., 10/14/16 at 4:00 p.m., 10/20/16 at 7:00 a.m. and 4:00 p.m. and on 10/21/16 and 10/22/16 at 4:00 p.m. 11. R17 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED].:00 p.m.). However, review of the (MONTH) (YEAR) MAR revealed there was no evidence that the medications were administered on 8/20/16 at 9:00 p.m. including the [MEDICATION NAME], Zocar and the [MEDICATION NAME] 25 units SQ at bedtime on 8/20/16. 12. R18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R18 had a physician's orders [REDACTED]. However, review of the (MONTH) (YEAR) MAR revealed there was no evidence that the insulin was given as ordered on [DATE], 8/18/16, 8/20/16 and 8/21/16. There was a physician's orders [REDACTED]. However, review of the (MONTH) (YEAR), (MONTH) (YEAR) and the (MONTH) (YEAR) MARs revealed there was no evidence that the insulin was administered as ordered on [DATE] and 8/22/16 at 6:30 a.m. and on 9/2/16 at 11:30 a.m., 9/8/16 at 11:30 a.m., 9/21/16 at 11:30 a.m. and 4:30 a.m., 9/26/16 at 11:30 a.m. and 4:30 p.m., 9/27/16 at 11:30 a.m. and 9/30/16 at 6:30 a.m. and 11:30 a.m. and on 10/20/16 at 6:30 a.m., 10/23/16 at 11:30 a.m. and on 10/24/16 at 6:30 a.m. There was a physician's orders [REDACTED]. ordered by the physician on 8/7/16 and 8/16/16 at 11:30 a.m. and 4:30 p.m., 8/19/16 at 4:30 p.m., 8/21/16 and 8/22/16, and 8/29/16 at 6:30 a.m., and on 10/20/16 at 6:30 a.m. 13. R19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of the physician's order [REDACTED]./6/16 for FSBS before meals and at bedtime (scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m. and at 9:00 p.m.) and an order since 11/11/15 for [MEDICATION NAME] 20 units SQ twice a day (scheduled at 6:30 a.m. and 9:00 p.m.). However, review of the (MONTH) MAR revealed and the [MEDICATION NAME] and [MEDICATION NAME] was not administered and the FSBS was not obtained at 6:30 a.m. on 8/21/16 as ordered by the Physician due to the lack of nursing coverage on the Secured Unit at that time. Further review of the (MONTH) MAR revealed there was no evidence that the [MEDICATION NAME], Solace, [MEDICATION NAME] were not administered and the FSBS was not obtained on 8/20/16 at 9:00 p.m. Interview with the previous Director of Nursing on 10/25/16 at 3:35 p.m., she confirmed that the 9:00 p.m. FSBS were not done as ordered for the entire month of (MONTH) (YEAR). She stated the staff failed to transcribe the order over to the MAR and that the nurses should have caught the error. 14. R21 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. [REDACTED].:00 p.m.) an order since 7/30/13 for [MEDICATION NAME] 40 mg at bedtime (scheduled for 9:00 p.m.) and an order for [REDACTED]. However, review of the (MONTH) (YEAR) MAR revealed that the [MEDICATION NAME] and [MEDICATION NAME] was not administered on 8/21/16 at 6:30 a.m., and there is no evidence that [MEDICATION NAME], [MEDICATION NAME] and the [MEDICATION NAME] were administered on 8/20/16 at 9:00 p.m. 15. R22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. There was an order since 8/12/14 for [MEDICATION NAME] 50 mg twice a day (scheduled at 9:00 a.m. and 9:00 p.m.), an order since 4/17/15 for [MEDICATION NAME] 20 mg three times a day (scheduled for 9:00 a.m., 5:00 p.m. and 9:00 p.m.) and an order since 5/22/14 for [MEDICATION NAME] 160 mg everyday (scheduled at 9:00 p.m.). However, review of the (MONTH) (YEAR) MAR revealed that the [MEDICATION NAME] and [MEDICATION NAME] were not administered on 8/21/16 at 6:30 a.m. and the [MEDICATION NAME] and [MEDICATION NAME] were not administered on 8/20/16 at 9:00 p.m. 16. R23 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. | 2019-11-01 |