| 56 |
WILLOWBROOKE COURT AT COUNTRY HOUSE |
85003 |
4830 KENNETT PIKE |
WILMINGTON |
DE |
19807 |
2019-07-15 |
760 |
D |
0 |
1 |
N66611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews and review of facility documentation as indicated, it was determined that for one out of one death record review, the facility failed to ensure that R48 was free of any significant medication errors. R48 missed an 8 AM dose of an intravenous (IV) antibiotic, [MEDICATION NAME], on 5/30/19 due to the facility not having enough IV tubing equipment on hand to administer the medication. Despite the facility receiving Stat (immediately) IV tubing from the pharmacy at 12:38 PM, the facility retimed R48's next dose for 6 PM, which resulted in a further delay of treatment. R48 received the next dose at 6:30 PM, approximately 6 hours after the Stat IV tubing was delivered. Findings include: The facility's pharmacy policy entitled LTC Facilities: Receiving Pharmacy Products and Services from Pharmacy, last revised on 1/2/13, stated, .Procedure .4. The pharmacy will provide stat medication orders that are not available in the facility's emergency drug supply within one hour of the time ordered during normal pharmacy hours . Review of R48's clinical record revealed: 5/28/19 - The hospital's Medication Orders Upon Discharge for R48 stated to administer [MEDICATION NAME] intravenously every 12 hours. 5/28/19 at approximately 12 Noon - R48 was admitted to the facility for IV antibiotic therapy status [REDACTED]. 5/28/19 - A physician's orders [REDACTED]. 5/30/19 at 8 AM - Review of R48's (MONTH) 2019 eMAR revealed that the resident's IV antibiotic, [MEDICATION NAME], was not administered at 8 AM. 5/30/19 at 8:56 AM - A nurse's note stated, NP (E6) made aware of missing IV tubing. Pharmacy called and new IV tubing to be sent out STAT. 5/30/19 at 12:38 PM - The pharmacy's Proof of Delivery record revealed that R48's IV tubing was received by the facility at 12:38 PM. 5/30/19 at 2:08 PM - An Order-Administration Note for R48's IV antibiotic [MEDICATION NAME] stated, .Waiting for pharmacy. 5/30/19 at 2:41 PM - A nurse's note stated, .Unable to give 0900 (9 AM) abt. (antibiotic) DR (doctor) made aware. Tubing arrived. Dosage schedule has changed . Despite the delivery of the Stat IV tubing at 12:38 PM according to the pharmacy's record, the facility did not administer R48's IV antibiotic. 5/30/19 at 6 PM - R48's (MONTH) 2019 eMAR revealed that the timing of the resident's IV antibiotic was changed from 8 AM and 8 PM to 6 AM and 6 PM. 5/30/19 at 6:30 PM - An Order-Administration Note revealed that R48 received the IV antibiotic. The facility delayed R48's IV antibiotic treatment 6 additional hours after the Stat IV tubing was delivered to the facility. 7/10/19 at 9:03 AM - During an interview, E2 (former DON) stated that the hospital sent R48's discharge information to the facility on Friday, 5/24/19. E2 stated that E4 (ADON) reviewed everything to ensure the facility had everything in place for R48 before he/she was admitted on Tuesday, 5/28/19. E2 stated that the pharmacy provided all IV equipment, including the IV pump, IV tubing and IV medication. 7/10/19 at 2:36 PM - During a combined interview with E2 (former DON) and E4 (ADON), when asked about the missing IV antibiotic dose due to the lack of IV tubing available, E2 confirmed that the facility should have had an emergency backup of IV tubing and he/she had addressed this with the pharmacy. E4 stated that the pharmacy told her the delivery would be in 4 hours for the Stat request. 7/11/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (interim DON) and E6 (NP). The facility failed to ensure that R48 was free of any significant medication errors when R48 missed an 8 AM dose of an IV antibiotic on 5/30/19 due to the facility not having enough IV tubing equipment on hand to administer the medication. Despite the facility receiving Stat IV tubing from the pharmacy at 12:38 PM, the facility retimed R48's next dose for 6 PM, which resulted in a further delay of treatment. R48 received the next dose at 6:30 PM, approximately 6 hours after the Stat IV tubing was delivered. |
2020-09-01 |