cms_GA: 4951
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 |
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4951 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2016-03-21 | 490 | J | 1 | 0 | Z2SU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, and review of established corporate policy and procedures, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently, to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to ensure resident drug therapy was administered safely, accurately, and in accordance with physician's orders [REDACTED].#1 and #2) from a total survey sample of twenty-four (24) residents. Resident #1, with a physician order [REDACTED].(MONTH) 4, (YEAR), when he was transferred to an acute longterm care facility. Resident #2, who did not have an order for [REDACTED]. On (MONTH) 25, (YEAR), a determination was made that a situation in which the facility's non-compliance with one or more of the requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Corporate Clinical Consultant, Director of Health Services (DHS) and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on (MONTH) 25, (YEAR) at 5:00 p.m. The Immediate Jeopardy was identified to have existed on (MONTH) 14, (YEAR), when the facility failed to ensure the accurate administration of medication to Resident #2. An allegation of jeopardy removal was received on (MONTH) 26, (YEAR). Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on (MONTH) 1, (YEAR), and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed for resident pictures. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Findings include: Review of the Corporate policy entitled Medication Discrepancies and Adverse Reactions revealed medication discrepancies and adverse reactions are to be reported to the patient/residents attending physician, the consultant and provider pharmacists, and the Pharmaceutical Services Subcommittee and/or the Quality Assurance Committee. Review of Procedure, Section 5 indicated a Medication Discrepancy/Adverse Drug Reaction Report is to be completed. Section 8 revealed the report is to be reviewed by the consultant pharmacist and on a quarterly basis by the Pharmaceutical Services Subcommittee and/or the Quality Assurance Committee and acted upon as appropriate. In addition to reporting discrepancies that result in the patient receiving an incorrect medication, medication discrepancies that have the potential for but do not actually result in the patient receiving an incorrect medication are documented and reported. Review of the Corporate Policy entitled Medication Administration; General Guidelines, Procedure #7 revealed patients/residents are identified before medication is administered. Procedure #9 indicated that in no case should the individual who administered the medications report off duty without first recording the administration of any medications. Procedure #10 revealed medications are to be administered within 60 minutes before or after scheduled time. Procedure #11 revealed after medication administration the patient/residents MAR indicated [REDACTED]. Review of Lippincott Procedures- Pain management, provided by the administrator when a pain management policy was requested, revealed under subheading of Giving medications: [REDACTED]. Reassess pain in a timely manner according to the onset of the prescribed medication. Reassessment should include not only pain relief but also adverse reactions or events produced by treatment. Cross refer to F329 regarding the facility's failure to administer [MEDICATION NAME] according to the Corporate Policy entitled Medication Administration: General Guidelines Cross refer to F333 regarding the facility's failure to administer medication correctly to Resident #1 and Resident #2, according to physicians orders, and according to the Corporate Policy entitled Medication Administration General Guidelines. Cross refer to F 520 regarding the failure of the Facility's Quality Assurance Committee to adequately monitor a plan of action to ensure an accurate and easily accessible method for staff unfamiliar with the resident's names to identify them for safe medication administration. In an interview conducted on 2/18/16 at 5:15 p.m. with the facility Corporate Clinical Nurse Consultant revealed she had investigated the administration of [MEDICATION NAME] 20 mg SL twice within thirty (30) minutes to Resident #1 on 12/20/15, but did not think this was an error because he did not receive an extra dose. The Corporate Clinical Nurse Consultant acknowledged the Medication Administration: General Guidelines policy indicates medications are to be given within one hour before or after the scheduled dose and this medication was administered ninety minutes late, but she did not think this was an error. The Consultant acknowledged BB LPN had not signed for 2 doses of [MEDICATION NAME] on the MAR indicated [REDACTED]. The Corporate Clinical Consultant confirmed [MEDICATION NAME] administration to a debilitated resident with a [DIAGNOSES REDACTED]. She acknowledged the [MEDICATION NAME] 20 mg SL had been administered every 2 hours on 12/20/15 beginning at 9:30 p.m. until the resident was discovered in respiratory distress with an oxygen saturation of 55%, and the only assessment for the 7:00 p.m. to 7:00 a.m. shift appeared on the reverse side of the MAR indicated [REDACTED]. Interview with the Clinical Competency Coordinator (CCC) on 2/23/16 at 9:45 a.m. revealed when LPN BB LPN and LPN AA were oriented in (MONTH) there was no CCC. The Minimum Data Set (MDS) Coordinator had to oversee staff education and orientation in addition to other assigned duties. She resigned in December, (YEAR). The CCC acknowledged the orientation of nurses has always consisted of a general orientation checklist, a skills checklist, computer learning modules, a medication test, and learning med pass with a preceptor. In an interview conducted on 2/24/16 at 3:00 p.m. with the Consultant Pharmacist, she revealed the Medication Discrepancy and Adverse Reaction reports were to review, track and trend medication errors and determine the need for interventions such as staff education. She acknowledged she had received a verbal report when Resident #2 received 2 antihypertensive medications and she had offered to observe a medication pass by LPN BB, but since BB was only in the building at night and on weekends she was not able to do this. The Consultant Pharmacist indicated she had also been made aware of Resident #1 receiving 2 doses of [MEDICATION NAME] within 30 minutes and his subsequent [MEDICAL CONDITION] the next morning and since he was admitted to the hospital she did not review any documentation for Resident #1. The Consultant Pharmacist acknowledged she had consulted for the facility since 2007 and had never received a completed Medication Discrepancy and Adverse Reaction Report. She confirmed these reports should be completed for any deviation from the Five Rights of Medication Administration, including right resident, right medication, right route, right time and right dose. Interview conducted on 2/25/16 at 3:30 p.m. with the Administrator revealed the administration of 2 antihypertensive medications ordered for Resident #4 and administered to Resident #2 on 10/14/15, was considered an error. The Medical Director had been notified and the error had been reported in the (MONTH) QA meeting. The intervention of assuring pictures of all the residents were on the MAR's had already been initiated and this was supposed to be monitored monthly by the unit managers. The Administrator acknowledged that on observations on 2/19/16 at 2:10 p.m. and on 2/25/16 at 10:40 a.m., of the one hundred eight (108) MAR's in the facility, there were six (6) missing pictures. The administrator indicated the unit managers must not be checking the MAR's for pictures. Continued interview revealed that Medication Discrepancy and Adverse Reaction forms were not completed for Resident #1 after receiving 2 doses of [MEDICATION NAME] within 30 minutes, or receiving scheduled doses of [MEDICATION NAME] every 2 hours without assessment of respiratory status or level of consciousness, or for Resident #2 who was administered his room mates medications. The Administrator revealed she had verbally informed the Consultant Pharmacist and the QA Committee of these situations, but there was no record of this. The facility had not completed these reports for any medication error for an unknown length of time. On 03/21/16 an extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice. Interview conducted on 3/21/16 at 1:30 p.m. with the Administrator revealed there had been only one (1) medication error on 2/29/16. Resident #22 received [MEDICATION NAME] 0.5 mg by mouth (po) twice daily (BID) until 2/9/16 when the order was changed to [MEDICATION NAME] 0.5 mg po every day (QD). On 2/29/16 Nurse AA administered a second dose of [MEDICATION NAME] 0.5 mg to R#22 at 9:00 p.m. The Administrator revealed this had been identified as an error as the Director of Health service (DHS) had monitored the Controlled Drug Records the next day and an incident report was made, family and physician were notified and a Medication Discrepancy and Adverse Reaction form was completed according to corporate policy. These records were reviewed and found to be complete. R#22 was observed according to physician order [REDACTED]. The Quality Assurance Committee had not held a meeting but would be informed at the next meeting. Nurse AA had terminated her employment with the facility during a disciplinary discussion of the incident with the DHS. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion. | 2019-03-01 |