cms_AK: 92

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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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
92 PROVIDENCE TRANSITIONAL CARE CENTER 25018 910 COMPASSION CIRCLE ANCHORAGE AK 99504 2017-06-22 332 D 0 1 NLCD11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review the facility failed to ensure their medication (med) error rate was below 5%. Specifically, the facility failed to ensure 1 resident (#1), out of 7 residents observed during med pass observations, had received physician ordered medications at the correct scheduled times. In addition, the facility failed to ensure the medication error had been reported. The failure to follow the safe medication administration practices placed the resident at risk for not receiving necessary medications and placed all residents at risk for medication errors from a systemic failure to identify a root cause analysis of medication errors. Findings: Record review on 6/20-22/17 revealed Resident #1 was admitted to the facility 4/26/17 with [DIAGNOSES REDACTED]. The Resident was at the facility to receive rehabilitation for an anticipated discharge home. Observation during a med pass on 6/20/17 at 1:50 pm revealed Licensed Nurse (LN) #4 prepared to administer medications to Resident #1. The LN removed 1 [MEDICATION NAME] 75 mg (a blood thinner) and 1 [MEDICATION NAME] 40 mg (an antidepressant) from the medication cart and administered them to the Resident. Review of the electronic Medication Administration Record [REDACTED]. Continuous observation on 6/21/17 from 7:20 am until 1:50 pm revealed the Resident was awake, ate breakfast, went to occupational therapy (OT) and physical therapy (PT) in the rehab department located in the building down the hallway, and returned to the unit and ate lunch. The Resident was not offered any scheduled morning medications during that time frame. During an interview on 6/20/17 at 1:50 pm, LN #4 stated Resident #1 had not received any of his/her am medications because the Resident had been in rehab all morning. Further review of the EMAR on 6/20/17 at 3:00 pm revealed the [MEDICATION NAME] and [MEDICATION NAME] had not been signed off. In addition, the medications Polyethylene [MEDICATION NAME] powder (used for constipation); sennosodes-[MEDICATION NAME] Sodium (used for constipation); [MEDICATION NAME] (long acting insulin); calcium [MEDICATION NAME] ([MEDICAL CONDITION]); and [MEDICATION NAME] (anticonvulsant used for neuropathic pain) had not been signed. Review of the Pyxis (medication dispensing system) report with LN #6, on 6/20/17 at 4:25 pm, revealed the Resident's am medications had been pulled from the Pyxis medication cart on 6/20/17 at 8:46 am. During an interview on 6/21/17 at 4:00 pm, when asked about the am medications not being given because the Resident was in the rehab department, the facility's Pharmacist #1 stated he/she would have expected the Resident to receive the medications either prior to attending therapy or after he/she had returned. The Pharmacist stated not administering the medications at the right time was considered a medication error and am medications were to be given by 10:30 am. The Pharmacist stated all medication error reports came to him/her and he/she had not received a medication error report on this incident. During an interview on 6/22/17 at 1:15 pm, LN #8, the nurse educator for the LNs, stated am meds needed to be given by 10:30 am. Review of the nurses' notes for 6/20/17 revealed at 8:21 pm [MEDICATION NAME]; calcium [MEDICATION NAME]; [MEDICATION NAME]; and senna (sennosodes-[MEDICATION NAME]) had not been documented as given. The reason listed was out of the building. Review of the facility policy Medication Administration Times, revised 12/16 revealed Facility administration times for oral and topical medications . Assigned Time Acceptable Time Range .d. AM 0800 0730-1030 . Review of the facility policy Medication Error Documentation, revised 1/15, revealed A medication error has occurred when .c. The dose is administered more than 1 hour early or late .e. A dose is omitted . Review of the facility policy Medication Administration, revised 12/16, revealed Medication errors are reported to the resident's prescriber and the pharmacy manager. An Unusual Occurrence Report is completed. 2020-09-01