cms_WV: 4513
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4513 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 332 | D | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and, review of Omnicell (an automated medication dispensing system) usage reports, and staff interview, the facility failed to ensure a medication error rate of less than five percent (5%). The medication error rate was 12.5 percent with four (4) errors in thirty-two (32) opportunities for error. A resident received the wrong dosage of aspirin, two (2) doses of medication would have been missed if not for surveyor intervention, and one (3) dose of medication was omitted. Resident identifiers: #50 and #88. Facility census: 45. Findings include: a) Resident #50 During a medication administration observation, on 11/11/15 at 8:14 a.m., Licensed Practical Nurse (LPN) #42 administered the following medications to Resident #50: [MEDICATION NAME] 25 milligrams (mg) orally (PO), Aspirin 81 mg PO, [MEDICATION NAME] 100 mg PO, [MEDICATION NAME] 0.6 mg PO, [MEDICATION NAME] 25 mg PO, and [MEDICATION NAME] 5 mg PO. Review of the medical record, at 10:00 a.m. on 11/11/15, revealed an order for [REDACTED].>A follow-up interview with LPN #42 at 10:30 a.m. on 11/11/15, confirmed [MEDICATION NAME] should have been administered with the medication administration at 8:14 a.m. The LPN reviewed the medications in the medication cart and related none was available to give. Upon inquiry, LPN #42 related [MEDICATION NAME] was available in the Omnicell emergency kit, and acknowledged she could have administered the dose. Upon inquiry regarding administration of the multivitamin, LPN #42 related she did not realize she had not administered the medication. Review of the Omnicell usage report, at 12:30 p.m., on 11/11/15 revealed LPN #42 removed four (4) [MEDICATION NAME] 5 mg tablets from the Omnicell machine at 11:45 a.m. for administration to Resident #88. b) Resident #88 During another medication administration pass with Licensed Practical Nurse (LPN) #42, on 11/11/15 at 8:20 a.m., the LPN administered Aspirin 81 milligrams (mg) orally (PO) to Resident #88. She related no [MEDICATION NAME] was available in the medication cart and would have to order it from the pharmacy. Review of the Medication Administration Record [REDACTED] A follow-up interview with LPN #42 at 9:45 a.m. revealed the Omnicell (automated dispensing system) contained medications which could be obtained and administered if not available in the medication cart. The nurse confirmed [MEDICATION NAME] was available for administration, and could have been obtained during medication administration. Upon request, LPN #42 identified the bottle utilized to administer Aspirin. The bottle was labeled Aspirin 81 mg. The nurse reviewed the physician's orders [REDACTED]. The LPN related Resident #88 should have received Aspirin 325 mg orally. Upon request, an Omnicell usage report was obtained from the pharmacy, and was reviewed on 11/11/15 at 12:30 p.m. The report confirmed [MEDICATION NAME] was pulled from the Omnicell at 9:43 a.m. and administered late. c) During a review of the medical records and the Omnicell report with the director of nursing (DON) on 11/11/15 at 12:45 p.m., the DON confirmed [MEDICATION NAME] was administered late to Resident #50, and [MEDICATION NAME] was administered late to Resident #88, but could have been administered timely if obtained from the Omnicell during the medication administration pass. The DON also acknowledged the medications would have been missed if not for surveyor intervention. | 2019-10-01 |