cms_WV: 155
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 155 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 711 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician signed and dated all orders. This was random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #94, #9, and #95. Facility census 182. Findings included: a) Resident #94 On 10/08/19 at 2:59 PM, during a review of the thinned medical record for a bed hold notification, the surveyor discovered several physician orders [REDACTED]. On 10/08/19 at 3:50 PM, Employee #73, Health Information Coordinator, confirmed that the physician orders [REDACTED].#73 was asked to copy all orders that were flagged. The following orders had not been signed by the physician: --03/21/19 16:02 - [MEDICATION NAME] HCI Tablet 20 MG Give 1 tablet by mouth every 8 hours for abdominal pain. discontinue --03/21/19 16:02 - [MEDICATION NAME] HCI Capsule 10 MG Give 1 capsule by mouth every 6 hours as needed for abdominal pain related to postsurgical malabsorption, not elsewhere classified --03/19/19 05:25 - Apply nourishing skin cream to bilateral lower extremities including feet, every shift for dry skin. discontinue --03/19/19 05:27 - Cleanse bilateral buttocks and coccyx with warm soapy water, rinse, pay dry, apply inzo barrier cream topically every shift for increased risk of skin breakdown and as needed. --03/19/19 05:27 - Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water, rinse, pat dry, apply [MEDICATION NAME] cream topically as needed AND every shift for increased risk of skin breakdown. discontinue --03/19/19 05:28 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply inzo barrier cream topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, as needed for wound healing and every shift for wound healing. --03/19/19 05:30 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply thin layer [MEDICATION NAME] paste topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, as needed for wound healing and every shift for wound healing. --03/19/19 05:41 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply inzo barrier cream topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, as needed for wound healing AND every shift for wound healing. discontinue --03/19/19 06:43 - ROHO cushion to wheelchair at all times, verify placement every shift for wound healing. --03/16/19 07:48 - BMP on Monday 3/18/19 one time only for hypertension until 03/18/2019 23:59 --03/17/19 17:33 - Send resident to CHH ER to replace PICC line d/t (due to) TPN use. one time only until 03/17/2019 23:59. --03/08/19 11:51 - Senna-S-Tablet 8.6-50 MG (Sennosides-[MEDICATION NAME] Sodium) Give 2 tablet by mouth every 24 hours as needed for constipation 2 tablets = 17.2 mg/100mg. Hold 03/08/19 11:51 --03/11/19 11:50 loose stool --02/28/19 16:13 - Sodium Chloride Flush Solution Use 50 ml/hr intravenously in the morning for BUN and Creatinine trending up related to postsurgical malabsorption, not elsewhere classified via central line - while TPN is not Scheduled to run (9am-9pm). --02/28/19 16:13 - Sodium Chloride Flush Solution Use 50 ml/hr intravenously in the morning for BUN and Creatinine trending up related to postsurgical malabsorption, not elsewhere classified via central line - while TPN is not Scheduled to run (9am-9pm). discontinue increased weight gain --02/28/19 16:04 - House Supplement three times a day sugar free health shakes - no straws. discontinue weight gain --02/22/19 14:58 - THERAPY: Occupational Therapy Evaluation and Treatment. discontinue Highest practical level met --02/25/19 08:00 - [MEDICATION NAME] Tablet 20 MG ([MEDICATION NAME]) Give 1 tablet by mouth two times a day related to essential (primary) hypertension; chronic combined systolic (congestive) and diastolic (congestive) heart failure. discontinue --02/25/19 13:23 - CBC Due to cough, BMP due to CKD, BNP due to [MEDICAL CONDITION] one time only until --02/26/2019 23:59 --02/25/19 13:36 - [MEDICATION NAME] Tablet 40 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day related to localized [MEDICAL CONDITION]. discontinue. Increased dose --02/25/19 13:28 - [MEDICATION NAME] Tablet 40 MF ([MEDICATION NAME]) Give 1 tablet by mouth one time a day for localized [MEDICAL CONDITION]. --02/25/19 13:30 - [MEDICATION NAME] Tablet 20 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day for localized [MEDICAL CONDITION]. --02/22/19 13:30 - TPN: Upon competition of infusion, discontinue and discard unused TPN and tubing. Change needleless connectors and flush line. RN to perform in the morning. --02/22/19 13:30 - TPN: Upon competition of infusion, discontinue and discard unused TPN and tubing. Change needleless connectors and flush line. RN to perform in the morning. discontinue. Clarification --02/22/19 13:26 - [MEDICATION NAME] Solution 10 % Use 1 liter intravenously as needed for if TPN not available or interrupted via central line - see detailed order under other --02/22/19 13:26 - [MEDICATION NAME] Solution 10 % Use 1 liter intravenously as needed for if TPN not available or interrupted via central line - see detailed order under other DISCONTINUE. Clarification. --02/22/19 13:2 - Infusion Set Miscellaneous (IV Sets - Tubing) 1 unit miscellaneous as needed for non-sterile, tubing disconnected, malfunction etc CHANGE 1.2 Micron filter tubing to infuse TPN. Ensure appropriate filter. Label with initials, date, and time. RN to perform AND 1 unit miscellaneous at bedtime for routine care / TPN infusion CHANGE 1.2 Micron filter tubing to infuse TON, Ensure appropriate filter. Label with initials, date, and time, RN to perform. --02/22/19 13:23 - Infusion Set Miscellaneous (IV Sets - Tubing) 1 unit miscellaneous as needed for non-sterile, tubing disconnected, malfunction etc CHANGE 1.2 Micron filter tubing to infuse TPN. Ensure appropriate filter. Label with initials, date, and time. RN to perform AND 1 unit miscellaneous at bedtime for routine care / TPN infusion CHANGE 1.2 Micron filter tubing to infuse TON, Ensure appropriate filter. Label with initials, date, and time, RN to perform. discontinue. Order clarification. --02/22/19 13:16 - Misc. Devices Miscellaneous 1 unit miscellaneous as needed for missing, damaged, etc change central line needleless connectors AND 1 unit miscellaneous in the morning for routine care change central line needleless connectors upon completion of TPN lipids daily. (RN to perform) AND 1 unit miscellaneous every day shift every Fri for routine care change central line needleless connectors with CVC dressing changes. --02/22/19 13:17 - Misc. Devices Miscellaneous 1 unit miscellaneous as needed for missing, damaged etc change needleless connectors AND 1 unit miscellaneous one time only for admission for 1 Day change needleless connectors with CVC dressing changes AND 1 unit miscellaneous in the morning for routine care change needleless connectors upon completion of TPN lipids daily. (RN to perform) AND 1 unit miscellaneous one time a day every Fri for routine change needleless connectors with CVC dressing changes. DISCONTINUE. Order clarification. --02/22/19 13:12 - Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) Use 10 ml intravenously as needed for blood draws, etc flush central line AND Use 10 ml intravenously two times a day for routine care flush central line with 10 mls NSS upon starting and completion of TPN and lipid infusion. --02/22/19 13:12 - Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) Use 10 ml intravenously as needed for blood draws, etc AN Use 10 ml intravenously two times a day for routine care flush with 10mls NSS upon starting and completion of TPN and lipid infusion. discontinue Order clarification. --02/22/19 07:00 - Ensure dressing to left chest tunneled IJ central line is clean dry and intact. Monitor site for increased [MEDICAL CONDITION], [DIAGNOSES REDACTED], bleeding, drainage. Document in nurses note and follow up with Provider as needed every shift. --02/22/19 13:09 - Ensure dressing to left tunneled IJ central line is clean dry and intact. Monitor for increased [MEDICAL CONDITION], [DIAGNOSES REDACTED], bleeding, and drainage. Notify provider. every shift (change dressing if C/D/I). discontinue. Order clarification. --02/22/19 13:06 - Sodium Chloride Flush Solution Use 75 ml/hr intravenously every shift for BUN and Creatinine trending up related to POST SURGICAL MALABSORPTION, NOT ELSEWHERE CLASSIFIED (K91.2) via central line-while TPN is not running. --02/22/19 13:07 - Sodium Chloride Flush Solution Use 75 ml/hr intravenously every shift for BUN and Creatinine trending up related to POST SURGICAL MALABSORPTION, NOT ELSEWHERE CLASSIFIED (K91.2) WHILE TPN IS NOT RUNNIN[NAME] DISCONTINUE. Clarification. On 10/09/19 at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON) and no further information was provided. On 10/09/19 at 5:05 PM, the Medical Director stated that she cannot sign orders electronically, she still has to sign orders with a pen. b) Resident #9 On 10/08/19 at 2:59 PM, during a review of the thinned medical record for a bed hold notification, the surveyor discovered several physician orders [REDACTED]. On 10/08/19 at 3:50 PM, Employee #73, Health Information Coordinator, confirmed that the physician orders [REDACTED].#73 was asked to copy all orders that were flagged. The following orders had not been signed by the physician: --06/28/19 21:02 - Monitor raised area on forehead every shift for injury for fall --06/28/19 16:46 - Apply ice to raised area on forehead X (times) 20 min every 4 hours for injury from fall for 1 Day --06/28/19 16:46 - Neuro Checks in place for 72 hrs per facility protocol every shift for related to fall for 3 Days. --06/27/19 10:26 - Resident to move to room [ROOM NUMBER] B --06/27/19 13:30 - [MEDICATION NAME] Tablet 0.5 MG (LORazepram) Give 1 tablet by mouth one time a day related to generalized anxiety disorder --06/27/19 13:31 - [MEDICATION NAME] Tablet 0.5 MG (LORazepram) Give 1 tablet by mouth two times a day related to generalized anxiety disorder. discontinue. --06/27/19 13:31 - [MEDICATION NAME] Tablet 25 MG (QUEtiapine [MEDICATION NAME]) Give 2 tablet by mouth two times a day for refusal of care related to attention-deficit [MEDICAL CONDITION] disorder, predominately hyperactive type; adjustment disorder with mixed anxiety and depressed mood monitor and document outcome every shift . discontinue --06/27/19 13:33 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day related to generalized anxiety disorder 3 Days. --06/27/19 13:34 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time a day related to generalized anxiety disorder. discontinue. --06/27/19 13:32 - [MEDICATION NAME] Tablet 100 MG (QUEtiapine [MEDICATION NAME]) Give 1 tablet by mouth at bedtime for refusal of care related to attention-deficit [MEDICAL CONDITION] disorder, predominately hyperactive type Monitor and document outcomes. --06/27/19 13:50 - HSG CCD diet. HSF Mech Soft texture. Regular consistency, with ground meat and gravy supervision with all meals, double portions. --06/27/19 13:50 - HSG CCD diet, HSG Puree texture, Regular consistency, supervision with all meals, double portions. discontinue. Diet upgrade. --06/14/19 11:28 - Send resident to (local hospital) to be evaluated /treatment for [REDACTED]. --06/12/19 13:53 - [MEDICATION NAME] Solution 5 MG/ML ([MEDICATION NAME]) Inject 1 ml intramuscularly one time only for increased behaviors and combativeness for 1 Day --06/12/19 15:00 - Eternal Feed-Bolus: [MEDICATION NAME] HN - TWO CANS (474 cc) - via [DEVICE] in the morning related to DYSPHASI[NAME] DISCONTINUE. Per provider orders, resident to obtain nutrition through PO (by mouth) nutrition --06/12/19 15:00 - Apply barrier cream topically to bilateral buttocks, coccyx, and sacrum after each incontinent episode every shift for incont (incontinent) episodes, etc. --06/12/19 15:00 - Cleanse bilateral buttocks and coccyx with warm soapy water. Rinse and pat dry-apply Inzo barrier topically every shift for increased risk for skin breakdown AND as needed for increased risk for skin breakdown. discontinue --02/21/19 01:31 - [MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 0.25 ml sublingually every 4 hours as needed for pain must document at least 3 non-pharmalogical interventions and outcome of those interventions prior to administration --02/21/19 01:31 - [MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 0.25 ml sublingually every 4 hours as needed for pain must document at least 3 non-pharmalogical interventions and outcome of those interventions prior to administration. discontinue --02/21/19 12:46 - Monitor Vital Signs three times a day for 3 Days --02/11/19 14:35 - PLO [MEDICATION NAME] Gel (Premium Lecith Organogel Base) Apply to forearm topically two times a day related to unspecified dementia with behavioral disturbance 75mg/2ml-apply 2 ml. --02/11/19 14:38 - [MEDICATION NAME] XR Capsule Extended Release 24 Hours 74 MG ([MEDICATION NAME] HCI ER) Give 1 capsule via PE[DEVICE] one time a day for major [MEDICAL CONDITION]. discontinue. Changed route. --02/09/19 07:37 - Apply ice to Back of head for 15 minutes and then remove for 2 hours, repeat process as directed, every shift for unwitnessed fall for 1 Day. --02/09/19 06:21 - Cleanse skin tear to left elbow with NS, pat dry, apply TAO, non-adherent pad, wrap with [MEDICATION NAME], every day shift for 7 Days --02/09/19 06:21 - Neuro checks x 72 hours d/t (due to) fall every shift for 3 Days. --02/08/19 21:19 - Enteral: Mic-Key tube necessary to malnutrition and dysphasia-may not change at facility --02/08/19 21:19 - Enteral: PEG tube necessary to malnutrition and dysphasia - may not change at facility. discontinue. --02/07/19 18:02 - Enteral: Two-Cal HN at 55 ml/hr via PEG tube for 21 hours, 7 hours, on/1 hour off with 200 ml flushes every 3 hours-total K/cal 2310/24 hours every 8 hours. Turn tube feeding on AND every 8 hours Turn tube feeding off. DISCONTINUE. Changed to bolus feedings. --02/07/19 17:41 - Bolus: TWO CAL HN - TWO CANS - in the morning related to dysphasia, unspecified. --02/07/19 17:41 - Bolus: TWO CAL HN 237 cc at bedtime related to dysphasia, unspecified. --02/07/19 17:41 - Bolus: TWO CAL HN 237 cc in the afternoon related to dysphasia, unspecified. --02/07/19 17:41 - Bolus: TWO CAL HN 237 cc in the evening related to dysphasia, unspecified. --02/07/19 17:41 - FLUSHES: 250 cc free water flushes every 4 hours related to dysphasia, unspecified. --02/07/19 17:40 - [MEDICATION NAME] Tablet 5-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet enterally every 6 hours for pain --02/07/19 17:40 - [MEDICATION NAME] Tablet 5-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet via PE[DEVICE] every 8 hours for pain. discontinue Increased frequency d/t pain --01/27/19 02:33 - Neuro checks per facility policy for 72 hours. every shift for unattended fall for 3 Days. --01/27/19 02:41 - Cleanse abrasion to left elbow with NSS (normal saline solution), pat dry, and apply TAO. (MONTH) discontinue when healed. --01/27/19 02:43 - Cleanse abrasion to right cheek with NSS, pat dry, and apply TAO. (MONTH) discontinue when healed. --01/23/19 12:06 - Paste Base Paste Apply to bil buttocks, coccyx, sac topically every shift for incontinence acquired [MEDICAL CONDITION] for 14 Days Cleanse bilateral buttocks, coccyx, and sacrum with normal saline, apply magic buttpaste ([MEDICATION NAME] 1%, [MEDICATION NAME] 1:1:1 mix equal parts 180 GM AND Apply to bil buttocks, coccyx, and sacrum with normal saline, apply magic buttpaste ([MEDICATION NAME] 1%, [MEDICATION NAME] 1:1:1 mix equal parts 180 GM. --01/23/19 12:11 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply inzo barrier cream topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, every shift for wound healing/increased risk for skin breakdown AND as needed for wound healing/increased risk for skin breakdown. DISCONTINUE. Wound rounds completed with Dr. Pinson and IDT. Paste base paste orders for bilateral buttocks, coccyx and sacrum d/t incontinence acquired [MEDICAL CONDITION]. Wound care will follow prn (as needed) and upon nurses request. --01/22/19 06:50 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply inzo barrier cream topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, every shift for wound healing/increased risk for skin breakdown AND as needed for wound healing/increased for skin breakdown. --01/22/19 06:49 - Cleanse bilateral buttocks and coccyx with warm soapy water. Rinse and pat dry-apply Inzo barrier cream topically every shift for increased risk for skin breakdown AND as needed for increased risk for skin breakdown. --01/22/19 06:49 - Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply Inzo barrier cream topically every shift for increased risk for skin breakdown AND as needed for increased risk for skin breakdown. discontinue. --01/22/19 13:13 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet via PE[DEVICE] two times a day for increased agitation related to generalized anxiety disorder monitor and document outcome every shift. DISCONTINUE. Increasing frequency. --01/22/19 13:13 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth every 8 hours related to generalized anxiety disorder . --01/22/19 13:22 - HSG Puree diet HSG Puree texture, Nectar consistency, for pleasure food. --01/22/19 13:23 - HSG NPO (Nothing by Mouth) diet NPO (Nothing by Mouth) texture, NPO (Nothing by Mouth) consistency. discontinue. Hospice accepted resident has new diet order. --01/17/19 08:33 - Hospice Consult one time only for 1 Day. --01/16/19 11:53 - Flush PEG tube with 200cc water for hydration /to maintain patency every 3 hours. --01/15/19 15:21 - ADC: Do Not Resuscitate - Comfort - no IV fluids. If feeding tube has been removed by resident-leave out. --01/15/19 15:28 - ADC: Do Not Resuscitate - DNR - Limited interventions - R.N. may pronounce death-May have IV fluids for trial period-Feeding tube long-term. discontinue. Updated. --01/13/19 21:57 - [MEDICATION NAME] Cream 1 % Apply to abdomen topically two times a day for skin irritation apply to affected area around peg tube site. --01/12/19 0:39 - Apply sureprep to wound on left lateral malleolus. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, every shift for wound healing AND as needed for wound healing. discontinue. Resolved. --01/12/19 07:23 - Consult: Occupational Therapy may evaluate and treat as indicated. --01/12/19 07:23 - Consult: Physical Therapy may evaluate and treat as indicated. --01/12/19 07:23 - Consult: Speech Therapy may evaluate and treat as indicated. --01/11/19 13:51 - [MEDICATION NAME] HCI Solution Reconstituted 750 MG Use 750 mg intravenously two times a day related to bacteremia. discontinue. VAMC discontinued. --01/11/19 13:51 - IV Catheter Kit 1 unit miscellaneous as needed for dressing not clean dry and intact Change PICC line dressing (Pharmacy please send central line dressing change trays) AND 1 unit miscellaneous every night shift every Mon, Fri for routine PICC care Change PICC line dressing (Pharmacy please send central line dressing change trays). discontinue. discontinued. --01/11/19 13:52 - Misc. Devices Miscellaneous 1 unit miscellaneous as needed for blood draw, malfunction, dressing changes, etc. Change needleless connectors (Pharmacy please send needleless connectors) AND 3 unit miscellaneous every night shift every Mon, Fri for routine PICC care Change needleless connectors (Pharmacy please send needleless connectors). discontinue. discontinue --01/11/19 13:52 - Kendall Luer Disinfectant Cap Miscellaneous (Parental Therapy Supplies) 1 unit miscellaneous as needed for missing, damaged etc change alcohol cap AND 1 unit miscellaneous in the morning for routine PICC care change alcohol cap after IV administration AND 3 unit miscellaneous every night shift every Mon, Fri for routine dressing changes change alcohol caps to all lumens. --01/06/19 17:05 -[MEDICATION NAME] HCI Solution Reconstituted 750 MG Use 750 mg intravenously two times a day related to bacteremia. --01/06/19 17:12 - [MEDICATION NAME] trough 30 minutes prior to 4th dose on 1/18/19 at 5 am. one time only for 1 Day. --01/05/19 18:03 - [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 1 tablet by mouth one time only for increased agitation and refusal of care until 01/05/2019. --01/07/19 03:00 - Neuro checks every 30 min. x 4, every 1 hour x 4 hours x 24 hours, every 8 hours for the remaining 72 hours. discontinue. Order was for 72 hours only. --01/07/19 15:25 - left hip X-ray d/t fall/pain. discontinue. obtained. negative. --01/07/19 15:24 -Send to CHH ER/IR for replacement of PICC line d/t resident pulled out 1/4/19 at 8pm. discontinue. completed. --01/03/19 18:26 - XRAY OF BILATERAL HIPS, 2 VIEW STAT for FALLS/PAIN. --01/04/19 01:57 - Hold [MEDICATION NAME] until trough obtained one time only for 1 Day. --01/04/19 01:58 - [MEDICATION NAME] trough 30 minutes prior to 4th dose one time only for 1 Day. --01/04/19 05:58 - Cleanse skin tear to right forearm with normal saline, pat dry, cover with [MEDICATION NAME], wrap with kerflex. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, as needed for skin tear for 10 Days AND every night shift for skin tear for 10 Days. --01/04/19 05:58 - Ensure dressing to right forearm is CDI (clean, dry, intact) every shift for ensure dressing is CDI for 10 Days. --01/02/19 17:30 - Apply sureprep to wound on left heel. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, every shift for wound healing AND as needed for wound healing. discontinue. resolved. --01/02/19 11:03 - Low bed with bilateral floor mats at all times while in bed-verify position and placement every shift for history of falls. --01/02/19 11:04 - Floor mat to left side of bed AAT's (at all times) every shift for falls. --01/02/19 11:04 - Low Bed AAT's while in bed every shift for falls. --01/02/19 07:00 - Safety checks every shift for history of falls complete paper safety checks form. --01/02/19 11:11 - Safety checks every 30 minutes. --12/31/19 20:46 - Count number of steri strips and document. Leave steri strips in place until they fall off. every shift for skin tear. discontinue. new orders noted On 10/09/19 at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON) with no further information provided. On 10/09/19 at 5:05 PM, the Medical Director stated that she cannot sign orders electronically, she still has to sign orders with a pen. c) Resident #95 On 10/08/19 at 2:59 PM, during a review of the thinned medical record for a bed hold notification, the surveyor discovered several physician orders [REDACTED]. On 10/08/19 at 3:50 PM, Employee #73, Health Information Coordinator, confirmed that the physician orders [REDACTED].#73 was asked to copy all orders that were flagged. The following orders had not been signed by the physician: --07/12/19 - Order Summary Report --09/21/19 08:12 - CBC, CMP q (every) 6 months d/t (due to)[MEDICAL CONDITION](hypertension) due Feb & Aug one time a day every 181 days(s) --09/21/19 08:12 - CBC, BMP q (every) 6 months d/t HTN. discontinue. Order clarification. --09/21/19 08:09 - vit d level one time only until 10/16/2019 23:59 --09/21/19 08:09 - vit d level one time only for 1 Day --09/21/19 08:08 - CMP, TSH, T4, FLP, annually due 07/2020 one time a day every 364 days(s) --09/21/19 08:08 - CMP, TSH, T4, FLP annually due 07/2020. DISCONTINUE. Order clarification. --09/19/19 20:51 - Acidophilus Capsule (Lactobacillus) Give 1 capsule by mouth every 12 hours for GI protection secondary to antibiotic use related to unspecified escherichia coli (E. coli) as the cause of diseases classified elsewhere unitary tract infection, site not specified. --09/19/19 20:51 - [MEDICATION NAME] Capsule 100 MG ([MEDICATION NAME] Monohyd Macro) Give 1 capsule by mouth two times a day related to unspecified escherichia coli (E. coli) as the cause of diseases classified elsewhere urinary tract infection, site not specified. for 7 Days. --09/19/19 20:52 - Nursing Progress Note every shift for antibiotic monitoring related to unspecified escherichia coli (E. coli) as the cause of diseases classified elsewhere urinary tract infection, site not specified. for 7 Days Also monitor closely for loose stools related to recent hx of [DIAGNOSES REDACTED] --09/19/19 20:55 - Vital Signs every 8 hours for antibiotic monitoring related to unspecified escherichia coli (E. coli) as the cause of diseases classified elsewhere urinary tract infection, site not specified for 7 Days. --09/19/19 20:55 - vitals q shift every 8 hours for 3 Days. --08/25/19 17:34 - Acidophilus Tablet (Lactobacillus) Give 1 tablet by mouth two times a day for ATB Therapy for 3 Days --08/25/19 17:34 - [MEDICATION NAME] Solution Reconstituted 1 GM (cefTRIAX Sodium) Inject 1 application intramuscularly at bedtime for UTI for 3 Days until finished. --08/25/19 17:38 - Temp Q shift while receiving ATB every shift for ATB Therapy for 3 Days. --07/16/19 11:52 - CMP in am one time only for 1 Day --07/16/19 11:52 - CMP in am one time only for 1 Day. discontinue --07/16/19 16:22 - Resident to be out of bed via hoyer lift for lunch daily every day shift for improved participation. On 10/09/19 at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON) and no further information was provided. On 10/09/19 at 5:05 PM, the Medical Director stated that she cannot sign orders electronically, she still has to sign orders with a pen. | 2020-09-01 |