cms_WV: 9377
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9377 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2012-11-09 | 309 | D | 1 | 0 | R50Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility's medication error reports, the facility failed to ensure two (2) of five (5) sample residents were provided the necessary care and services to attain or maintain their highest practicable physical well-being. Resident #130 was ordered [MEDICATION NAME], a medication for fungal infections of the nails, but was administered the medication [MEDICATION NAME], a [MEDICAL CONDITION] medication, for fifty-three (53) days. Resident #135 was administered the wrong inhaler. Resident identifiers: #130 and #135. Facility census: 159. Findings include: a) Resident #130 Review of the facility's medication error reports, on 11/07/12, at 1:30 p.m., found an incident dated 07/03/12. The medication error report identified Resident #130, was ordered [MEDICATION NAME] 250 mg every day for four (4) weeks. ([MEDICATION NAME] is a medication used to treat certain fungal infections of the nails.) The order was transcribed to the Medication Administration Record [REDACTED]. According to the medication error report, the correct medication was not received from the pharmacy. The pharmacy sent [MEDICATION NAME], a medication used to treat [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. This medication error was identified when the pharmacist completed a review of the facility's medication cart on 07/03/12. The medication error report identified the error was discovered by a pharmacy cart check. During an interview with Employee #119 (director of nursing), on 11/07/12, at 1:45 p.m., it was confirmed the facility ordered the correct medication, [MEDICATION NAME], but the pharmacy sent [MEDICATION NAME] instead. Nursing staff administered the incorrect medication and did not identify the medication error. She stated, When medication is received from the pharmacy, the orders are checked with the Medication Administration Record [REDACTED]. On 11/07/12, at 2:30 p.m., Employee #119 also confirmed the error was discovered during a pharmacy cart check. She described this was when a pharmacy tech compared the medication to the MAR. Employee #119 further added, This is not completed monthly. She stated she was not certain how often it occurred, but thought it might be quarterly. At 3:46 p.m. on 11/07/12, Employee #119 confirmed nursing staff should have compared the MAR indicated [REDACTED]. It was re-ordered on [DATE], and again the pharmacy sent the wrong medication. The facility failed to verify the correct medication was provided by pharmacy, resulting in Resident #130 receiving [MEDICATION NAME], a [MEDICAL CONDITION] medication, instead of [MEDICATION NAME], a fungal infection medication, from 05/12/12 thru 07/03/12. b) Resident #135 Review of the medical record, on 11/07/12, at 8:15 a.m., identified this resident had the following physician orders [REDACTED]. The [MEDICATION NAME] diskus was ordered on [DATE]. The resident also had an order for [REDACTED]. Review of medication incident reports identified the resident was administered the [MEDICATION NAME] inhaler at the wrong time. The resident received both the [MEDICATION NAME] inhaler and the [MEDICATION NAME] Diskus inhaler on 09/01/12 at the 9:00 p.m. medication pass. At that time, she should not have received the [MEDICATION NAME] inhaler. The physician was not notified until 09/09/12 at 11:30 a.m. During an interview with Employee #141 (registered nurse), at 8:47 a.m. on 11/07/12, he confirmed the medication error which occurred on 09/01/12. He said the licensed practical nurse (LPN) administered the [MEDICATION NAME] Inhaler at the 9:00 p.m. medication pass; however, the [MEDICATION NAME] inhaler was only to be given at the morning medication pass. He confirmed the resident was supposed to receive only the [MEDICATION NAME] Inhaler. Employee #141 stated the resident's daughter was in the room when the nurse gave the wrong medication. He stated the daughter told the nurse she administered the wrong medication. He stated he was not aware of the medication error until one (1) week later, when the resident's daughter came to him and told him the nurse had given her mother the wrong inhaler. Employee #141 confirmed nursing staff on duty at the time of the error did not report the incident, nor did they notify the physician. Employee #141 stated, I talked to the nurse about it and she confirmed she had given the wrong inhaler on 09/01/12. He stated the nurse was new and was not sure whether or not it was a medication error, because she was not sure if the resident had inhaled the medication. He stated the LPN did not know she needed to do a medication error report and did not know she needed to notify the doctor and the family about the error. Employee #141, stated, I was not made aware of the incident until 09/09/12. An interview was conducted on 11/07/12 at 1:00 p.m., via telephone, with Employee #73, (the LPN who administered the medication). She stated she gave the medication which was given by mouth first, then gave the inhaler last. Employee #73 stated the daughter told her she gave her mother the wrong inhaler. She said she went out to check the Medication Administration Record, [REDACTED]. Employee #73 stated she contacted her nursing supervisor and asked her if she should also administer [MEDICATION NAME], in addition to the [MEDICATION NAME]. She said her supervisor told her it would be all right, so she also gave the resident the [MEDICATION NAME]. Employee #73 said she did not think it was a medication error because the resident was supposed to get the medication anyway, and it was just given to her earlier than her next scheduled dose. Employee #72 confirmed she did not notify the physician at the time of administration, because she was not aware it was an error. | 2015-11-01 |