| 2 |
BURNS NURSING HOME, INC. |
15009 |
701 MONROE STREET NW |
RUSSELLVILLE |
AL |
35653 |
2019-08-21 |
554 |
D |
0 |
1 |
HHU111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and review of facility policies titled, MEDICATION ADMINISTRATION BY MOUTH and Self-Administration of Medication, the facility failed to ensure a licensed nurse remained with Resident Identifier (RI) #32, who had not been assessed for self-administration of medication, during the administration of [MEDICATION NAME] during medication pass observation on 08/21/19. This affected RI #32, one of four residents observed during medication pass observation and one of two nurses observed. Findings Included: A review of a facility policy titled, MEDICATION ADMINISTRATION BY MOUTH, with a REVISED DATE: 09/18/2014, documented: .9. The nurse will remain with resident/patient until medications are taken. A review of a facility policy titled, Self-Administration of Medication, with Date Implemented: (MONTH) (YEAR), revealed: .1.an assessment is conducted by the interdisciplinary team and results of the assessment are recorded on the Self-Administration Assessment Form, which is placed in the resident's medical record. 2. As part of the interdisciplinary team, a physician order [REDACTED]. The care plan must reflect resident self-administration and storage arrangements for such medications. RI #32 was admitted to the facility on [DATE]. A review of RI #32's medical record revealed no order for self-administration of any medications, no self-administration assessment form and no care plan for self-administration of medication. On 08/21/19 at 7:56 a.m., during medication pass observation, the surveyor observed Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), mix RI #32's [MEDICATION NAME] in four ounces of water in a plastic cup and deliver it RI #32's bedside, along with other medications. EI #1 administered all medications except [MEDICATION NAME]. Surveyor observed EI #1 instruct RI #32 to drink his [MEDICATION NAME]. EI #1 then left RI #32's bedside and entered the bathroom to wash her hands out of direct sight of RI #32. When EI #1 returned to the bedside, RI #32 handed her three plastic cups, two that contained liquid in them. EI #1 did not question RI #32 about the liquid remaining in the cups or if he/she had taken the [MEDICATION NAME]. On 08/21/19 at 1:31 p.m., an interview was conducted with EI #1, LPN. EI #1 was asked how long should she remain with a resident when administering medications. EI #1 said, until they get completely done. EI #1 was asked did she remain with RI #32 while he/she drank the water that [MEDICATION NAME] was mixed in. EI #1 responded she did not guess she did. EI #1 was asked, did RI #32 have an order to self-administer medications. EI #1 said no. EI #1 was asked had RI #32 been assessed to self-administer medications. EI #1 replied she did not think so. EI #1 was asked was RI #32 care planned for self-administration of medications. EI #1 replied not that she knew of and she had not seen it if he/she was. When asked what was the concern with not remaining with a resident until all medication was consumed or administered, EI #1 answered, somebody else could have gotten it or he/she could not have taken it. On 08/21/19 at 4:18 p.m., an interview was conducted with EI #2, Registered Nurse (RN)/Infection Control Preventionist/Minimum Data Set (MDS) Coordinator. EI #2 was asked how long should a nurse remain with a resident during medication administration. EI #2 said until all the medicines are taken. EI #2 was asked what should be in place before a resident can safely self-administer medications. EI #2 replied, an assessment form, physician order [REDACTED]. EI #2 was asked what was the concern with a resident self-administering medications without the proper assessment, physician's orders [REDACTED]. EI #2 answered, they could get the wrong dose, the wrong time or if it was left somebody could come by and pick it up that did not need it and the resident it was intended for may not get it. |
2020-09-01 |