cms_WV: 11422
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11422 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 425 | E | U2Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on review of medical records, review of reports from the facility's provider pharmacy and consultant pharmacists, staff interviews, review of the facility's pharmacy policy and procedure for adverse drug reactions, review of a list of drugs with the potential to interact with Coumadin, and the manufacturer's sheet for Coumadin, it was determined the facility had not implemented pharmaceutical services procedures to minimize medication-related adverse consequences or events. One (1) resident who was receiving Coumadin was ordered Bactrim DS for an infection. The resident fell and was later hospitalized . She was found to have subarachnoid bleeding. The hospital physician identified this may have occurred due to the resident receiving Bactrim DS and warfarin (Coumadin). The records of thirty (30) residents who were receiving warfarin were reviewed. Thirteen (13) were found to have orders for medications known to have major interactions with warfarin (a blood thinner). There was no evidence the potential for interactions had been identified by the pharmacists. Additionally, the facility's pharmacy manual included a policy which included notification when there was a potential adverse drug reaction (ADR). There was no evidence this policy had been implemented for residents receiving warfarin. Resident identifiers: #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131. Facility census: 150. Findings include: a) Residents #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131 A review of residents receiving the medication warfarin was prompted by a complaint allegation. On the morning of 10/26/10, a request was made for copies of the physicians' orders for residents who were receiving warfarin. A copy of the facility's policy for adverse drug reactions was also requested. Copies of the orders for thirty (30) residents were provided the afternoon of 10/26/10. The ordered medications were compared to the lists of drugs with a potential to interact with warfarin identified on the manufacturer's drug insert. These were further reviewed via the Internet at Drugs.com. Thirteen (13) of the thirty (30) residents were found to have one (1) or more drugs listed as having the potential to have major interactions with warfarin. All thirty (30) residents were receiving medications that had a potential to interact with warfarin, ranging from minor to moderate to major. For example: 1. Resident #29 This resident had an order for [REDACTED]. She was also receiving Gemfibrozil twice a day for [DIAGNOSES REDACTED]. This medication was listed on the manufacturer's package insert as having the potential, alone or in combination, to increase PT/INR response. According to the information found at Drugs.com, this medication was known to have the potential for a major interaction with warfarin. Bactrim DS, an antibiotic, was added to the resident's medication regimen on 10/10/10 and first administered on 10/11/10. According to information found in the manufacturer's package insert and Drugs.com, this medication also had a known potential to increase the PT/INR. 2. Resident #52 This resident was also receiving warfarin. Her other medications and potential interactions included: Fenofibrate - major Fluconazole - major Lovenox - major Cymbalta - minor Levothyroxine - moderate Omeprazole - moderate Ropinirole - moderate (She had been readmitted from the hospital on [DATE]) 3. Resident #137 The resident was receiving warfarin. Ciprofloxacin was ordered for twice a day for ten (10) days on 10/19/10. Ciprofloxacin is listed as having a major potential for interacting with warfarin. - b) The facility provided a copy of a policy / procedure regarding adverse drug reactions (ADR) as requested. This included: "Warfarin Interactions a) Determine if the drug interaction potential is serious and predict the timing of the interaction effect as advised by FDB (First Data Bank) . b) Recommend an alternate medication if possible (i.e. azithromycin instead of erythromycin or clarithromycin) or determine if a warfarin dosage adjustment is indicated. Determine the appropriate INR monitoring frequency if needed. Call the facility and document the intervention on Policy Form #038.3A and record any order or INR monitoring changes at the bottom as directed by the physician. c) If the interaction is NOT immediate or serious the dispensing pharmacist documents their review and assessment by overriding the hang-up in the computer and printing the FDB drug interaction sheet. d) The FDB drug interaction sheet is sent with the medication delivery or faxed to the facility. . . ." Random review of the residents receiving warfarin did not find any evidence of such notifications. The director of nursing was asked for copies of pharmacy recommendations the facility had received. She stated she had them back to May 2010. Approximately one hundred-forty (140) documents from the pharmacy to the facility were reviewed. The majority of these were regarding medication interchanges or need for hand written prescriptions for controlled substances. Only one (1) document addressing the potential for drug-drug interactions was found. This was for Resident #131. On 10/27/10, the consultant pharmacist provided a report that included, "____ takes warfarin (Coumadin) and is also on other medications which may have pharmacodynamic and / or pharmacokinetic interactions: furosemide, acetaminophen, Lexapro, metoprolol, Nexium, and Ropinirole." The recommendation included, "When changing doses, stopping or starting other medications in a resident on warfarin, please consider more frequent INR monitoring, until stable." On 11/02/10 at 12:20 p.m., the ADR policy was discussed with the director of nursing (DON). She stated the pharmacy had not been sending the notices referenced in the policy. A short while later, the DON reported they had received a list of drugs that interacted with warfarin. On 11/02/10 at approximately 4:20 p.m., Employee #192 provided a copy of the document the DON had referenced. The document listed antibiotics and anti-infectives that interacted with warfarin. Among the drugs listed under the heading "HIGH SEVERITY : Serious risk - Action must be taken" were Bactrim, Ciprofloxacin, and Fluconazole. Next to this list of medications was "Notify physician for warfarin dose reduction (as necessary) and repeat PT/INR per physician recommendation." --- Part II -- Based on review of medical records, staff interviews, review of sign-out sheets for the emergency drug box in Building 2, and a counting of the number of doses of Bactrim DS in the emergency drug box, it was determined an accurate accounting of the dispensing of medications from the emergency supply had not been ensured. Resident identifier: Unknown, but possibly Resident #29. Facility census: 150. Findings include: a) Resident #29 an order for [REDACTED]. Review of Resident #29's medical record found the antibiotic had been scheduled to be started at 9:00 a.m. on 10/11/10. However, the box for the nurse's initials on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview at 9:57 a.m. on 10/27/10, Employee #53 said she had gotten the antibiotic from the emergency box. Then she paused and said she had given Tylenol, not the antibiotic. According to documentation on the MAR, Resident #29 did not receive the first dose of the antibiotic until 9:00 p.m. on 10/11/10. On 10/27/10 at 3:35 p.m., Employee #36 was asked to provide access to the emergency box. The sign out sheets were located in the medication room. According to the sheet for October 2010, no Bactrim DS had been administered from the emergency box. The information on the sheet indicated there should have been twenty (20) doses of Bactrim DS in the box. An actual count of the medication found there were nineteen (19) doses, not twenty (20) doses of Bactrim DS in the emergency box. It was unknown to whom the medication had been given. . | 2014-03-01 |