cms_AK: 9
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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9 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 514 | E | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to maintain accurate and complete medical records. Specifically, the facility failed to: 1) document the indication of use for medications in the residents' medical record for 4 residents (#s 1; 3; 4 and 10) out of 10 sampled residents whose medical records were reviewed, and 2) accurately document the current medical treatment (saline lock flush and pain medication) for 1 resident (#5) out of 7 sampled residents. These failed practices placed the residents at risk for not receiving services needed to address medical conditions. Findings: Indications for Use of Medications: Resident #1 Record review from 5/16-19/17 revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the current medication administration record (MAR) and medication order detail revealed no documentation of [DIAGNOSES REDACTED]. Resident #3 Record review from 5/16-19/17 revealed Resident #3 was admitted to the facility with [DIAGNOSES REDACTED].) and frequent falls. Review of the current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #4 Record review on 5/16-19/17 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Further review revealed Resident #4's medication regime included: 1) Atorvastatin ([MEDICATION NAME]) - used to treat high cholesterol 2) [MEDICATION NAME] ([MEDICATION NAME]) - an antidepressant 3) [MEDICATION NAME] ([MEDICATION NAME]) - an antidepressant 4) [MEDICATION NAME] ([MEDICATION NAME]) - a diuretic Review of the current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. Resident #10 Record review on 5/18-19/17 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of Resident #10's medication regime revealed Resident #10 was taking the antipsychotic medication [MEDICATION NAME] 10 mg nightly. Review of the current MAR and medication order detail, revealed no documentation of [DIAGNOSES REDACTED]. During an interview on 5/18/17 at 1:00 pm, Pharmacist #1 stated the indication for use for all medications should be on the MAR and order details. The Pharmacist confirmed the facility was missing the indications for use on some of the Resident's medications. Review of the website Institute for Safe Medication Practices, accessed on 5/30/17 at http://www.ismp.org/tools/guidelines/SCEMI/SCEMIGuidelines.aspx, revealed, Provide a field to enter the purpose/indication for all medications communicated electronically .Communicating the drug's indication reduces the risk of improper drug selection and offers clues to proper dosing when a medication has an indication-specific dosing algorithm. Documented Accuracy of Medical Treatment: Resident #5 Saline Flush Record review from 5/16-18/17 revealed Resident #5 was admitted to the facility with failure to thrive and gastrointestinal hemorrhaging. Random observations from 5/15-18/17 revealed, Resident #5 had a saline-locked intravenous (IV) access located in forearm. Record review from 5/16-18/17 of the most current physician's orders [REDACTED]. Record review from 5/16-18/17 of the current MAR revealed no documentation or order for the administration of saline through the IV access. During an interview on 5/18/17 at 10:08 am, Pharmacist #1 and #2 both stated there should have been an order for [REDACTED]. In addition, Pharmacist #1 and #2 stated the MAR should reflect the order to ensure documentation of the saline administration was in a resident's chart. Review of the facility provided IV access guidelines, undated, revealed a peripheral IV should be flushed every eight hours with 10 milliliters normal saline. Pain Medication Order Record review of Resident #5's MAR, dated 5/2017, revealed the following order: [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME] - narcotic pain medication) 5-325 mg per tablet, 1-2 tablets every four hours as needed for moderate to severe pain. Further review revealed the nurses had been administering the [MEDICATION NAME] prior to wound dressing changes. During an interview on 5/17/17 at 12:57 pm, the Medical Director stated an order should be written to specify the use of [MEDICATION NAME] prior to wound dressing changes to reflect a more accurate portrayal of the Resident's medical record and care and ensure the Resident is receiving the appropriate pre-treatment pain medication. During an interview on 5/18/17 at 8:15 am the Charge Nurse (CN) confirmed the nurses had been providing the [MEDICATION NAME] prior to wound dressing changes each day. | 2020-09-01 |