cms_GA: 444

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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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
444 DUNWOODY HEALTH AND REHABILITATION CENTER 115270 5470 MERIDIAN MARK ROAD, BLDG E ATLANTA GA 30342 2018-08-30 580 D 1 0 IJ9V11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and Physician interview, and review of facility education and policy, the facility failed to notify Physicians of unavailable medications for two (2) residents (R) (R#3 and R#5) from a sample of five (5) residents reviewed for controlled medication administration. Findings include: 1. Record review for R#3 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of Nurse's Progress Notes indicated on 6/25/18 at 7:18 a.m. R#3 did not have a [MEDICATION NAME] Patch applied because it was not available, and the Physician and Pharmacy were notified. On 6/28/18 at 8:31 a.m. Nurse's Notes again indicated R#3 did not have a [MEDICATION NAME] Patch applied pending pharmacy delivery. A physician progress notes [REDACTED].#3 and he was experiencing phantom limb syndrome with pain. On 7/4/18 at 11:53 a.m. Nurse's Progress Notes revealed R# 3 did not have a [MEDICATION NAME] Patch applied because the pharmacy would deliver. On 7/7/18 at 12:48 p.m. a Nurse's Progress Note indicated R#3 did not have a [MEDICATION NAME] Patch applied because the medication was not available. On 7/10/18 at 9:26 a.m. R#3 did not have a [MEDICATION NAME] Patch applied because the pharmacy was to deliver the patch. The Medication Administration Records (MAR's) for (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed and the omissions above were confirmed. R#3 had missed five of seven Physician ordered applications of [MEDICATION NAME] Patches from 6/25/18 through 7/10/18. The next [MEDICATION NAME] 72 hour 25 mcg/hr patch applied was on 7/13/18 at 9:00 a.m. An interview conducted on 8/14/18 at 3:58 p.m. with R#3's Physician revealed she was not notified when she came to the facility to see R#3 that there was no prescription for the [MEDICATION NAME] Patch. The Physician revealed the transfer orders from the hospital usually come with the appropriate prescriptions so they can be sent to the Pharmacy immediately. The Physician revealed she visits each floor at the facility twice a week. The Physician confirmed she was unaware R#3 had missed three consecutive applications of the [MEDICATION NAME] Patch. 2. Review of the clinical record for R#5 revealed he was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #5's admission [DIAGNOSES REDACTED]. Review of Physician's Progress Notes for R#5 revealed the Physician had visited on 6/21/18 and R#5 had complained of [MEDICAL CONDITION]. The Physician had written a prescription, dated 6/21/18, [MEDICATION NAME] mg one by mouth at bedtime, and the quantity prescribed was thirty (30). The prescription was on the chart. Review of the Controlled Substance Proof of Use forms for R#5'[MEDICATION NAME] mg tablets revealed the medication was administered as ordered at bedtime until 7/7/18. Review of the Sum of Quantity Shipped sent by the pharmacy that listed every medication dispensed by the pharmacy for R#5, with quantity and date sent, revealed seven (7)[MEDICATION NAME] mg tablets had been sent for R#5 on 6/23/18. Seven [MEDICATION NAME] mg tablets were sent on 6/29/18. This was depleted on 7/6/18. According to the Sum of Quantity Shipped no [MEDICATION NAME] mg tablets had been received by the facility for R#5 until 7/18/18. The pharmacy was contacted for information regarding emergency dispenses for R#5 and on 8/28/18 at 2:22 p.m. sent a list that did not include any emergency dispenses [MEDICATION NAME] R#5 from 7/7/18 through 7/17/18. An interview was conducted with the Physician for R#5 on 8/30/18 at 6:55 p.m. The Physician revealed he usually leaves prescriptions to cover medications at least until the next weeks visit and remembered leaving a prescription for this medication. The Physician acknowledged if he had been notified the pharmacy was not sending this medication he would have told the nurse the prescription was on the chart and to resend it, or authorized an Emergency dispense until the problem could get straightened out. The Physician for R#5 confirmed the nurses usually call if there is a problem obtaining medications for his residents, but he was not aware R#5 was not administered his prescribed sleeping medication for ten days. Review of facility pharmacy policy, dated 12/1/07, titled Medication Shortages/Unavailable Medication, revealed if an emergency delivery is unavailable, facility nurse should contact the attending Physician to obtain orders or directions. If facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, facility nurse should notify the nursing supervisor and contact facility's Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage. An interview was conducted with the Unit Manager for R#3 and R#5 on 8/30/18 at 3:00 p.m. The Unit Manager revealed the nurses had not followed the policy to call the Physician when medications were not available. The Unit Manager confirmed that all the nurses administering medications were aware of the policy. 2020-09-01