cms_GA: 925
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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925 | LIFE CARE CENTER OF GWINNETT | 115347 | 3850 SAFEHAVEN DRIVE | LAWRENCEVILLE | GA | 30044 | 2017-10-12 | 425 | D | 1 | 0 | GRKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, staff interviews, record review, review of the facility Physician order [REDACTED].#1) of three (3) sampled residents. Findings include: An interview with the Complainant and the Resident's (R1's) Responsible party on 10/12/17 at 12:05 p.m. revealed R1's family believes the facility abruptly stopped administering Zoloft to R1 as prescribed, causing her mental health to decline and her dementia worsen and caused her recent fall and subsequent injury because it made her dizzy. Review of the clinical record for Resident (R#1) revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record Review revealed the resident had experienced a fall on 9/9/17 attempting to go to the toilet without assistance. The resident had sustained a laceration to her head requiring four staples to close to the wound. Review of the Physician order [REDACTED]. clarify and include in new order discontinuation of the existing order. Review of Physician orders [REDACTED]. Review of the Hospital discharge medicine list also revealed two orders for Sertraline 25mg 1 tablet by mouth daily. Further review of the physician's orders [REDACTED]. The order did not indicate that the order to discontinue was only for the duplicate order. An additional order dated 9/16/17 for Sertraline 25 mg tablet daily indicating the medication was resumed on 9/17/17. Review of the Medication Administration Record [REDACTED]. The order for Sertraline 25 mg one daily was not transcribed to the (MONTH) (YEAR) MAR until (MONTH) 17, (YEAR) indicating (R#1) did not receive medication as ordered by the Physician from (MONTH) 1, (YEAR)-September 16, (YEAR). Interview on 10/12/17 with Registered Nurse (RN)/Unit Manager HH revealed that R#1 was admitted to the facility with a prescription for Zoloft/Sertraline and another antidepressant medication. However, the hospital orders were duplicated in transcription, for Sertraline 25 mg one daily. The facility nurse reviewed the orders and intended to discontinue one of the orders because it was a duplicate. When we faxed it to the pharmacy, it was automatically discontinued and R#1 did not receive the Zoloft/Sertraline until the error was discovered. However, the resident did receive the Zoloft /Sertraline on 8/31/17.The order for Sertraline 25 mg tab by mouth at 9 a.m. for depression happened on time on 8/31/17 and resumed on 9/16/17 when the family asked if she was getting the medication. After this incident, the staff development nurse gave Licensed Practical Nurse LPN (II) training on how to transcribe when you have duplicate orders. I would expect my nurses to write that an order is duplicate on the orders if she was discontinuing a duplicate order. Interview on 10/12/17 at 5:21 p.m. with R#1's Physician revealed, the same way you can change one antidepressant to another, there is no detrimental effect for discontinuing Zoloft/Sertraline. It would not cause dizziness or disorientation. This is not a huge medical impact on the patient's quality of life causing major side effects. Interview on 10/12/17 at 5:51 p.m. with facility pharmacy consultant KK revealed if it's a high dose you would taper down over a few weeks to avoid side effects. R#1 was already a low dose and so it's hard to say it would contribute to a fall. I don't believe stopping a dose that low would be a factor. Interview on 10/12/17 at 6:35 p.m.-with Administrator-QA is monthly, and as needed and the medical director is there each meeting. We review all departments and we have a report from pharmacy. We have not had a QA meeting since this incident, if the nurses find an incident with a med error, the nurse's immediately educate. If there is a pattern, it's brought up in Q[NAME] I believe this incident was isolated. Things happen. We feel there is a process in place to make sure this does not happen again. We are going to put it in QA and address it in the next meeting. The nurses have monthly in-service meetings-this is not a pattern it was just a fluke but it is something we are keeping an eye on. We will be putting this in the QAPI. Interview 10/13/17 at 9:07 a.m. with the Dispensing Pharmacy General Manager revealed if the pharmacy receives an order to discontinue Zoloft/Sertraline, it will be discontinued off the profile. The system would have caught any duplication of the original orders and left only one (1) prescription if a duplicate order was submitted. The dispensing pharmacy encourages the facility to read through hospital orders and transcribe them before sending them to the dispensing pharmacy. On the dispensing pharmacy side, we would catch the duplicate and only fill it once. The facility should have just marked through the duplicate or discontinued the original order. It could be considered a documentation issue. The key is for the facility to review and transcribe orders and convert them to the dispensing pharmacy order sheet prior to submission, this is strongly encouraged, but not mandated. There is no way the pharmacist would question a discontinued order on the pharmacy side. We get a thousand discontinued orders a day. Sertraline is a common drug and it was ordered at a low dose, I can't see any pharmacy questioning the discharge of such a low dose of Sertraline. | 2020-09-01 |