cms_GA: 4401
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4401 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2016-12-10 | 332 | D | 1 | 0 | QBL111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure the facility's medication error rate remained below 5% when two of two nurses failed to administer medications as ordered for two of six residents observed during medication pass (Resident (R)#37 and Resident #71). One nurse administered the wrong dose of an ordered medication to R#37, and the second nurse required interruption in insulin administration to R#71 to prevent a medication error from occurring, and then used incorrect injection technique during insulin administration. These 3 errors out of 34 opportunities resulted in an 8.8% medication administration error rate. Findings include: 1. Observation on 12/8/16 at 10:25 a.m. revealed Licensed Practical Nurse (LPN) AD stated she planned to administer R#37's medications. During the pass, LPN AD opened a container of Fiber Powder and stated the physician ordered the resident to receive a dosage of 3.4 grams. The LPN looked at the clear plastic medication cup indented with measurement lines, and stated the cup did not have the proper measurement. LPN AD looked at the container and the cup again, and stated she planned to give a medication cup full of the powder. She filled the 30 milliliter medication cup with the powder, mixed it in two small glasses of water, and provided it to the resident who consumed it. Review of an order clarification, dated 10/4/16, indicated the order directed the staff to discontinue the [MEDICATION NAME] (Fiber Powder) powder 3.4 grams by mouth daily. It then directed the staff to give [MEDICATION NAME] one tablespoon by mouth daily for constipation. Review of the resident's record also revealed a physician's orders [REDACTED]. It directed the staff to give [MEDICATION NAME] 3.4 grams fiber powder daily at 9:00 a.m. During an interview on 12/10/16 at 9:15 a.m., LPN AH stated the staff had the order clarified from grams to make it easier for the staff to administer, but the clarification did not make it to the current Medication Administration Record (MAR). LPN AH looked at the medication cup and stated the resident should receive an amount equivalent to the 15 milliliter measurement line. (The resident received twice this amount.) During an interview on 12/10/16 at 1:35 p.m., the Director of Nursing (DON) reported she expected the staff to administer medications per the physician's orders [REDACTED].>2. Observation on 12/8/16 at 4:54 p.m. revealed LPN AL stated she planned to administer insulin to R#71. LPN AL and the surveyor reviewed the MAR and LPN AL stated the resident had a blood glucose level of 296 and needed a total of 24 units of [MEDICATION NAME]. After preparing her work area, the LPN inserted the syringe into the vial of [MEDICATION NAME] insulin, inverted the bottle and syringe, and squinted as she drew out the insulin. She moved away from the cart and stood under the light in the hallway, stating the darkness of the hallway made it difficult to see the syringe. She removed the syringe needle from the vial, pushed up the syringe's protective sheath, and placed the syringe on her medication cart. After putting the vial back in its box, the LPN picked up a vial of [MEDICATION NAME]and began the same process for drawing up the [MEDICATION NAME] into a second syringe. Observation of the [MEDICATION NAME] syringe at that time revealed only 22 units of [MEDICATION NAME] in the syringe. After LPN AL stated she had finished drawing up the second insulin, the surveyor stopped the LPN and requested that she have a second nurse check the [MEDICATION NAME]syringe. The LPN handed the syringe to Registered Nurse (RN) AB and he stated she needed to add two additional units to the syringe. LPN AL brought out the vial of [MEDICATION NAME]and added two units to the syringe. In the resident's room, the LPN cleaned an area on R#71's stomach. She inserted the needle of the syringe of [MEDICATION NAME] into the resident's skin at a very shallow angle. The shallow angle caused the medication to create a bump, or wheal, in the resident's skin, a type of administration also known as an intradermal injection (different than ordered by the physician). At that time, the resident stated discomfort from the injection. LPN AL gave the second insulin in the same manner, causing a bump to form in the resident's skin. Again, the resident voiced discomfort with the administration. When asked if a bump normally formed when she gave insulin, LPN AL stated, Yes, because it's given Sub Q. Review of the physician's orders [REDACTED]. Review of a second physician's orders [REDACTED]. Review of a third physician's orders [REDACTED].=2 units, 251-300=4 units, 301-350=6 units, 351-400=8 units, 401-450=10 units, 450 notify MD. During an interview on 12/10/16 at 1:35 p.m., the DON reported she expected staff to administer medications per the physician's orders [REDACTED]. | 2019-11-01 |