| 28 |
NORTH DECATUR HEALTH AND REHABILITATION CENTER |
115012 |
2787 NORTH DECATUR ROAD |
DECATUR |
GA |
30033 |
2017-02-09 |
329 |
D |
0 |
1 |
OC5011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to monitor two residents (R) for behaviors, that received antipsychotic medication (R#59 and R#90). The sample was 27 residents. Findings include: 1. Review of the physician orders [REDACTED]. Review of the Behavior Flow Sheet for (MONTH) (YEAR) revealed no evidence of behavior monitoring for hallucinations and wandering on the following dates and times: 2/3/17 on night shift 2/4/17 on night shift 2/5/17 on night shift 2/7/17 on night shift 2/8/17 on day, evening and night shift Further review of the medical record revealed no evidence of behavior monitoring for the months of October, November, and (MONTH) (YEAR) and (MONTH) (YEAR). An Interview on 2/9/17 at 7:55 p.m. with the Unit Coordinator DD confirmed there was no evidence of behavior monitoring for the dates noted in (MONTH) (YEAR). She further stated, in the past, the documentation of behaviors had been stored in a notebook, however, the notebook could not be located. 2. Review of the policy titled Behavior Management Guideline dated 11/1/16 revealed that each resident's drug regiment will be free from unnecessary drugs, defined as a drug when used without adequate monitoring. A care plan is developed for residents exhibiting negative behaviors or those on an antipsychotic medication, and a monitoring system is established for targeted behaviors and medication side effects and effectiveness. Review of records revealed Resident (R) #90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED].; and an Abnormal Involuntary Movement Scale (AIMS) to be completed quarterly. Review of the most recent quarterly Minimum Data Set (MDS) assessment for R#90 with a reference date of 12/19/16 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 10 which indicates the resident has a moderate cognitive impairment. Section [NAME] - Behavior - of the same assessment documented the resident exhibited no evidence of [MEDICAL CONDITION], and no behaviors such as verbal/physical aggression nor rejection of care during the previous seven days. Section I - Active [DIAGNOSES REDACTED]. Review of the resident's Annual MDS assessment with a reference date of 5/3/16 revealed that [MEDICAL CONDITION] drug use and behavioral symptoms triggered on Section V - Care Area Assessment (CAA) Summary - and the decision was made to complete a plan of care for these areas. Review of the Plan-of-Care for R#90, last revised 10/28/16 revealed a focus area related to the potential for drug-related complications associated with the use of antianxiety and antipsychotic medications, physical and verbal altercations with roommates and staff, and refusal of medications. The goal was for staff to monitor for psychiatric drug complications through the next review date. Interventions included: monitoring and reporting side effects to the attending physician; monitoring and documenting target behaviors such as symptoms of agitation, cursing, hitting at staff; and reporting behavioral changes to the physician. Review of the Plan-of-Care for R#90, last revised 10/28/16 revealed a focus area related to behaviors such as yelling during care, shouting, and cursing. The accompanying goal was for the resident to calm down with staff interventions. Those interventions included: staff to attempt interventions before behaviors begin; give meds as ordered; and let attending physician know if behaviors interfere with daily life. Review of the Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] HCL 50 mg, [MEDICATION NAME] 20 mg, and [MEDICATION NAME] 0.5 mg were administered as ordered. Review of nurses' progress notes and medication administration notes completed for R#90 from 2/1/16 through 2/7/17 revealed no documentation of adverse effects related to anti-psychotic use. Review of the records for R#90 revealed a quarterly Abnormal Involuntary Movement Scale (AIMS) was last completed on 1/12/17 with no symptoms of Tardive Dyskinesia related to the use of an anti-psychotic medication noted. Review of the records for R#90 revealed Behavior Monthly Flow Sheets on which staff were instructed to monitor and document the presence of behaviors such as agitation, [MEDICAL CONDITION], and uncooperativeness for the resident related to her use of anti-psychotic, antidepressant, and antianxiety medications. These monthly monitoring sheets were included in the resident's records for (MONTH) through November, (YEAR), and February, (YEAR). However, no behavior monitoring sheets were found for the months of December, (YEAR) and January, (YEAR). Interview conducted on 2/9/17 at 4:50 p.m. with AA, the staff member responsible for medical records, revealed that the administrative staff pulls behavior monitoring sheets each month from the monitoring book kept on the medicine carts and delivers these to the medical records department for filing in residents' records. However, he was never given a sheet for R#90 for (MONTH) (YEAR) or (MONTH) (YEAR). To his knowledge, behavior monitoring flow sheets were not completed for R#90 for these two months. Interview on 2/9/17 at 5:00 p.m. with Licensed Practical Nurse (LPN) BB revealed that the nurses are not required to routinely chart side effects unless side effects are noted. However, they are required to complete the behavior monitoring sheets for all residents receiving antipsychotic medications on every shift. Observation done at the time of the interview revealed Behavior Log on the medicine cart which contained Behavior Monthly Flow Sheets for R#90 and other residents being monitored for behaviors for the month of February, (YEAR). Behavior monitoring sheets for no other months were available in this log. |
2020-09-01 |