cms_GA: 4952
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4952 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2016-03-21 | 514 | J | 1 | 0 | Z2SU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, Controlled Drug Record review, and Medication Administration Record (MAR) review, the facility failed to accurately document medications administered for two (2) residents (R#1 and R#3), from a sample of twenty-four (24) residents. 1. Specifically for Resident #1, who had [DIAGNOSES REDACTED]. to failure to document the 7:00 a.m. dose on the resident's MAR or Controlled Drug Record after administration. R#1 had been admitted with an order for [REDACTED]. The Physician was contacted two (2) times with the residents' complaints of ongoing pain and the facility received 2 additional physician orders [REDACTED]. The facility failed to record the subsequent physician orders [REDACTED]. 2. Additionally, Resident #3 received [MEDICATION NAME] Insulin seventy (70) units subcutaneously (sq) four (4) times, administration of [MEDICATION NAME] Diskus one (1) inhalation 1 time and Fluvall 0.5 ml intramuscular (IM) 1 time, during the month of October, without the accompanying documentation on the MAR. This resulted in a situation in which the facility' s non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility' s Administrator, Director of Health Services (DHS), Corporate Clinical Consultant, and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on (MONTH) 25, (YEAR) at 5:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 14, (YEAR), the date another resident (#2) received two (2) antihypertensive medications with no order for these medications and was transferred emergently to the hospital, according to Nurses notes, fading in and out of consciousness with a blood pressure of 64/38. He was subsequently admitted to the ICU with a [DIAGNOSES REDACTED]. The Immediate Jeopardy continued through (MONTH) 20, (YEAR), the date Resident #1 received, due to an omission of documentation, two (2) doses of [MEDICATION NAME] 20 mg SL within 30 minutes, at 7:00 a.m. and 7:30 a.m. The night of 12/20/15 and the morning of 12/21/15, from 9:30 p.m. through 5:30 a.m. Resident #1 received [MEDICATION NAME] 20 mg SL every 2 hours without assessment of respiratory status, pain level and without regard to sedation level and education provided by a Nursing Supervisor advising the use of nursing judgement, the residents ability to use a pain scale to assess sedation, and the possibility of respiratory depression with the use of opioid medication. An interview with the Corporate Clinical Consultant on 2/18/16 at 5:00 p.m. revealed the investigation of these events had not resulted in identifying a problem with narcotic administration and monitoring or medication administration and documentation. The Immediate Jeopardy remained on going, pending the acceptance of a final Credible Allegation of Jeopardy Removal. Observations were made of medication administration to assess staff' s conformance with accurate documentation of medication administration. Record reviews were conducted to assess staffs conformance with correct scheduling of medications when transcribing orders to the Medication Administration Records. An allegation of jeopardy removal was recieved on (MONTH) 26, (YEAR). Based on 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 staff's compliance with physician's orders [REDACTED]. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Findings include 1. Record review for Resident #1 revealed an admission date of [DATE]. Physician orders [REDACTED]. Review of Physician orders [REDACTED]. This order did not specify the concentration or mg to be given. The next telephone order on the Physician order [REDACTED]. This order does not specify concentration of the liquid, route of administration or number of mg to be given. Review of the MAR for R#1 revealed the admission order for [MEDICATION NAME] had been transcribed with the concentration of 20 mg per ml, give 0.5 ml q 4 hours routinely. No time for the order appeared on the MAR and the times administered were recorded correctly. The next order transcribed to the MAR had no time when the order was received and was transcribed as [MEDICATION NAME] 1 ml q 3 hrs, with no concentration, mg, route or date. Two doses were signed as given on 12/19/15 at 8:00 a.m. and 11:00 a.m. The next order was written on the MAR as [MEDICATION NAME] 1 ml SL q 2 hours routine 12/19/15. No time of the order, concentration or mg was included. The order was initialed as given at 1:00 p.m. This order was marked as changed and rewritten with a concentration and no date or time and was initialed as given on 12/19/15 at 1:30 a.m., 3:30 a.m., 5:30 a.m., 7:30 a.m., and 9:30 a.m. These doses were recorded as administered before the order existed. The next four doses on 12/19/15 at 11:30 a.m., 1:30 p.m., 3:30 p.m. and 5:30 p.m. were correctly recorded on the MAR then at 7:30 p.m. and 9:30 p.m. initials were crossed out. The 11:30 p.m. dose was initialed as given. Continued review of the MAR for 12/20/15 revealed [MEDICATION NAME] 20 mg/ml 1 ml was initialed as administered every 2 hours until the initials were circled at 3:30 p.m., 5:30 p.m., 7:30 p.m. and 9:30 p.m., indicating these doses were not administered. At 11:30 p.m. the [MEDICATION NAME] was initialed as administered. On 12/21/15 at 1:30 a.m., 3:30 a.m. and 5:30 a.m. the [MEDICATION NAME] was initialed as administered. Review of the Controlled Drug Record for R#1 revealed [MEDICATION NAME] was correctly signed as given on 12/19/16 at 2:00 a.m. and 6:00 a.m. Then a 0.5 ml/ 10 mg dose had been signed out without a time. The next dose on 12/19/15 at 8:00 a.m. is a 1 ml 20 mg dose in conformance with the order. According to review of the Controlled Drug Record the next doses of [MEDICATION NAME] were administered as ordered until a 20 mg [MEDICATION NAME] dose was given on 12/20/15 at 7:00 a.m. and another was administered at 7:30 a.m. Review of Corporate policy entitled Physician order [REDACTED]. Review of Corporate policy entitled Medication Administration: General Guidelines revealed if a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time the space provided on the front of the MAR is initialed and circled and an explanatory note is entered on the reverse side of the record. Continued review revealed after medication administration the MAR is initialed by the person administering the medication. Record review of Nurses Notes dated 12/20/15 at 1:30 a.m. by Licensed Practical Nurse (LPN) BB revealed no indication that medication was not given at the scheduled times. Review of the reverse side of the MAR revealed no note regarding a variation in the time [MEDICATION NAME] was administered. The following note written by the 7:00 a.m. to 7:00 p.m. LPN AA on 12/20/15 at 8:05 p.m. revealed that upon checking narcotic count at 7:00 p.m. a medication error was found. The 7:00 p.m. to 7:00 a.m. LPN BB had not signed out the doses of [MEDICATION NAME] administered at 4:30 a.m. or 7:00 a.m. and the day shift nurse AA had assumed the [MEDICATION NAME] had been administered at the correct time, which would have been 5:30 a.m. and administered a dose of 20 mg [MEDICATION NAME] thirty (30) minutes later at 7:30 a.m. AA documented notification of the physician and family, and an assessment of the residents respiratory status. LPN AA noted the physician had responded that since the two doses within 30 minutes had occurred twelve hours previously any adverse reaction would have already occurred. Interview on 2/18/16 at 5:15 p.m. with the Corporate Clinical Consultant revealed that this incident had been investigated and since there were no doses of [MEDICATION NAME] missing and it had measured out correctly this was not considered to be an error. The Corporate Clinical Consultant revealed that the policy for medication administration allows for a one hour variation before or after the medication is due, the administration of a dose of [MEDICATION NAME] due at 4:30 p.m. and given ninety (90) minutes later at 7:00 a.m., even though it was thirty (30) minutes past the allotted hour, was not considered an error. The Corporate Clinical Consultant acknowledged that the omission of documentation for the doses administered at 4:30 a.m. and 7:00 a.m. had resulted in 2 doses being administered within 30 minutes and the resident, already with a [DIAGNOSES REDACTED]. The Clinical Consultant indicated the unaccounted for dose of [MEDICATION NAME] recorded on the Controlled Drug Report on 12/19/15 without a time between 6:00 a.m. and 8:00 a.m. had been questioned with LPN AA and she had been unable to give an explanation of this entry, but this was also not considered an error. Review of Nurses Notes for R#1 dated 12/23/15 revealed an entry as follows: Investigation completed by Admin SR RN Consultant, DHS (DON). All meds, doses accounted for. No med error. This entry was signed by the Corporate Clinical Consultant. Interview on 2/19/16 at 10:35 a.m. with LPN AA revealed that when writing the orders for the increased doses of [MEDICATION NAME] she did not know she needed to include the concentration and milligrams. A indicated she also had not known the time of the order, concentration, and milligrams needed to be transcribed on the MAR, but she had received clarification of the last order on 12/19/15 at 3:30 p.m. by calling the physician and she rewrote the order with the concentration and mg at that time. LPN AA revealed that she had difficulty writing the scheduled times and this resulted in doses being initialed that were not given, before the order was written, and the MAR really could not be deciphered due to crossed out initials, circled doses, missing documentation on the back of the MAR, as well as doses initialed that were not actually given. LPN AA revealed that she had asked another nurse on duty on 12/19/15 how to correct the MAR and they did not have any suggestions. AA was asked about the extra dose signed on the Controlled Drug Report on 12/19/15 between 6:00 a.m. and 8:00 a.m. and she was unable to account for this. LPN AA revealed that when she arrived for work on 12/20/15 at 7:00 a.m. she discovered two doses of [MEDICATION NAME] for R#1, scheduled for 3:30 a.m. and 5:30 a.m. were not initialed as given on the MAR or signed on the Controlled Drug Report. She reported she assumed they had been administered as scheduled and the next dose due at 7:30 a.m. was administered as scheduled. LPN AA further revealed that she should have called LPN BB but did not. She acknowledged the narcotic count had been performed that morning before LPN BB left and it had looked correct but it was difficult to see the liquid because it was clear and it must not have been counted correctly. Continued interview revealed that she left 2 spaces on the Controlled Drug Report and asked LPN BB to fill in the spaces as well as the empty spaces on the MAR, when she returned on 12/20/15 at 7:00 p.m. When LPN BB filled in the time for her administration due at 5:30 a.m. as 7:00 a.m. AA reported to the physician, family and facility. LPN AA revealed that she should not have left empty spaces on the Controlled Drug Record. Interview with LPN BB on 2/19/16 at 11:55 a.m. revealed that she remembers not signing the MAR and Controlled Drug Record on 12/20/15 for the 3:30 a.m. and 5:30 a.m. doses she had administered late at 4:30 a.m. and 7:00 a.m. She was unable to remember why she had administered these doses late or why she had not reported this to LPN AA , or why she had not signed as having administered the [MEDICATION NAME]. She acknowledged leaving the spaces blank on the MAR and not documenting them on the Controlled Drug Report, and not reporting giving the last dose 90 minutes late to the oncoming Nurse had resulted in 2 doses of [MEDICATION NAME] being administered 30 minutes apart and this could have caused the resident to have a serious adverse reaction. LPN BB revealed there was no disciplinary action regarding the missing documentation, but someone had told her to be sure to document medication administration. 2. Record review for Resident #3 revealed a re-entry date of 6/29/15, with an admission [DIAGNOSES REDACTED]. Review of the (MONTH) Physician orders [REDACTED]. Review of the MAR for Resident #3 for the month of (MONTH) revealed [MEDICATION NAME] Insulin 70 units had not been initialed as given on 10/12/15 at 9:00 p.m., on 10/29/15 at 9:00 p.m., on 10/30/15 at 9:00 a.m. and 9:00 p.m. [MEDICATION NAME] Diskus 250/50 one puff q 12 hours had not been initialed on 10/13/15 at 9:00 p.m. and Fluvall 0.5 ml IM to left deltoid was to be administered on 10/25/15 and was not initialed. Continued review of the clinical record revealed Resident #3 had been in the facility on the dates the above medications were to be administered and there was no clinical indication not to administer the medications. The back of the MAR for the month of (MONTH) does not indicate the [MEDICATION NAME] Insulin, [MEDICATION NAME] Diskus and Fluvall were held for any reason. The Nurses Notes for the month of (MONTH) were reviewed and no indication of holding these medication on the above dates could be found. Interview with the Administrator on 2/19/16 at 2:30 p.m. revealed the documentation omissions for [MEDICATION NAME] Insulin 70 units sq a.m. and hs had been investigated by the facility as a follow up to a Quality Assurance Intervention that was considered resolved in August, (YEAR). The facility had determined the insulin had been administered and the nurses had received written disciplinary action for not documenting according to policy. The MAR' s are supposed to be checked by the unit manager at the end of each shift but there was no unit manager on the South Hall for the month of (MONTH) and the MAR' s did not get checked. The administration of Fluvall was documented in the Nurses' notes but never was documented on the MAR and the missing initials were not addressed and the administration of the [MEDICATION NAME] Diskus on 10/13/15 at 9:00 p.m. was never investigated. The Administrator confirmed that nurses are expected to initial the MAR according to policy, as soon as a medication has been administered. Interview on 2/25/16 at 1:35 p.m. with LPN LL revealed that she received counseling regarding missing documentation of [MEDICATION NAME] Insulin on 10/12/15 at 9:00 p.m. and 10/30/15 at 9:00 a.m. and remembered she had administered the insulin but had not documented. LL acknowledged also giving the [MEDICATION NAME] Discus 250/50 one puff q 12 hours on 10/13/15 at 9:00 p.m. but failed to document. LPN LL confirmed that she was aware that not documenting the administration of medications could lead to serious harm to the residents. Interview on 2/25/16 at 1:30 p.m. with LPN FF revealed that she had administered [MEDICATION NAME] Insulin 70 units to R#3 on 10/29/15 and 10/30/15 at 9:00 p.m. and had not initialed the MAR. She indicated she received counseling and was aware that missing documentation could have serious consequences for the resident. Based on the above findings omission of documentation on the MAR immediately following medication administration had a high likelihood of causing harm to two residents, Resident #3 with undocumented insulin administration, and Resident #1, with undocumented [MEDICATION NAME] administration resulting in 2 doses being administered in thirty minutes. 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. Interview on 3/21/16 at 6:00 p.m. with the Director of Health Services (DHS) revealed all nurses are to monitor the MAR's for pictures and unsigned medications on the MAR's. The unit managers are also monitoring daily and the DHS monitors at least once weekly and checks the Controlled Drug Records against the MAR's, physician orders [REDACTED]. He further revealed he has not found any non-compliance. Medication pass is observed weekly for three (3) nurses, and the consultant pharmacist observes medpass monthly. 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. 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. | 2019-03-01 |