cms_GA: 811
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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811 | PRUITTHEALTH - AUGUSTA | 115334 | 2541 MILLEDGEVILLE ROAD | AUGUSTA | GA | 30904 | 2017-06-16 | 309 | D | 1 | 0 | TF3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assure that one resident, Resident #1 (R#1) of the three sampled residents recieved physican ordered pain medications until five days after admission to the facility. Facility census was 83. Findings include: Resident #1 (R#1) admitted [DATE] with a primary [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. A Pain Observation Form was completed on 6/12/2017 listing arthritis, [MEDICAL CONDITION], perineal and scrotal [MEDICAL CONDITION], shooting pain in legs, especially at night, discomfort to lower extremities, knees, and discomfort to buttocks. [MEDICATION NAME] 10/325 miligrams (mg) 1 by mouth every six hours as needed for pain. Review of the 'Admission Interim Care Plans Form' dated 6/12/2017 for R#1 revealed to 'administer pain medications per physician's orders [REDACTED]. Review of the out-patient medication orders, dated 6/9/2017 listed 23 active medications, including [MEDICATION NAME]-[MEDICATION NAME] 10 mg/[MEDICATION NAME] 325 mg to be taken one tablet by mouth every six hours as needed for pain. Review of the 'physician's orders [REDACTED]. Review of the 'Medication Record' dated 6/9/2017 reveals that resident did not receive any [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME] until 6/14/2017. Review of the 'Skilled Daily Nurses Note' dated 6/11/2017 at 5:00 a.m. reveals R#1 complained of lower limb pain and was given 650 mgs of Tylenol. Review of the 'Skilled Daily Nurses Note' dated 6/9/2017 reveals that [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME] had not been brought by the pharmacy yet. R#1 had some relief. Intensity of the pain was rated a '10' on a scale of 0-10, with 0 being no pain and ten being the highest pain. R#1 was complaining of shooting pain at night in both legs. Review of the 'Skilled Daily Nurses Note' dated 6/14/2017 at 5:30 p.m. reveal complaint of right lower extremity pain, no intensity documented. [MEDICATION NAME] administered for pain. Review of faxed requests to R#1's facility physician reveals physician was not contacted until 6/12/2017 (no time available) with a request to send renewal forms for R#1's [MEDICATION NAME] 10/325mg 1 tablet by mouth every six hours. An 'Approved Prescription' was received on 6/13/2017 at 4:57 p.m. that reads '[MEDICATION NAME]-[MEDICATION NAME] 10mg-325mg, Take 1 tablet(s) every 6 hours by oral route as directed for 30 days. Interview with the Director of Nursing (DON) on 6/16/2017 at 7:12 p.m. who states that the facility's physician was out of town at the time the resident was admitted and that the VAMC should have sent a written prescription with the resident for the [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME]. DON admits that no attempt was made to contact the on-call physician or call the VAMC for a prescription. Interview with the DON on 6/16/2017 at 9:05 p.m. who reveals that the on-call physician could have been contacted for a prescription and that there is no policy requirement that residents receiving narcotics must have a written prescription when admitted in order to receive narcotics. The DON futher reveals that the facility's physician will only write prescriptions for narcotics on Tuesdays and Fridays. Interview with R#1 on 6/16/2017 at 4:25 p.m. who reveals that he always has pain, but pain medications make the pain bearable. He requested pain medication the night he arrived but was told he did not have any yet. He asked again the following day when lunch was served and again that night. He was told by one of the nurses that he would not have a prescription until Tuesday because that's when the doctor wrote them. R#1 stated that he takes [MEDICATION NAME] for [MEDICAL CONDITION], and that staff gave him some Tylenol, but that was like drinking water, it didn't help. R#1 further states that he complained about pain every day. Interview with R#1 and FM AA on 6/16/2017 at 5:45 p.m. who reveal that resident always experiences some pain. AA reveals that she went to the nurse's station and asked for pain medication from staff and was told that resident needed a prescription from the doctor and they were attempting to get it. FM AA states that resident complained of pain everyday but all he received was Tylenol. | 2020-09-01 |