cms_GA: 3284
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3284 | NORTHSIDE GWINNETT EXTENDED CARE CENTER | 115645 | 650 PROFESSIONAL DRIVE | LAWRENCEVILLE | GA | 30046 | 2017-08-10 | 329 | E | 0 | 1 | 503S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility policy titled Unnecessary Medications review, the facility failed to ensure that one Resident (R#48) was monitored for signs and symptoms for the continued use of an antianxiety ([MEDICATION NAME]) (Cross Reference F280). The facility failed to ensure that one resident (R#73) had a gradual dose reduction (GDR) attempted for the continued use of an antipsychotic ([MEDICATION NAME]) and an antianxiety ([MEDICATION NAME]). Finally, the facility failed to ensure that there was a corresponding [DIAGNOSES REDACTED].#224) for the use of an antidepressant ([MEDICATION NAME]) of 25 sampled residents . Findings include: 1. Record review revealed R#48 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 3/2/16, the physician ordered [MEDICATION NAME] 0.25 milligrams (mg) to be administered per mouth twice daily for anxiety. A document entitled Plan of Care - Snapshot with an effective date of 1/25/17 identified that the resident had anxiety with the goal of .less than 2 episodes of anxiety per week . There was a care plan for R#48's use of [MEDICAL CONDITION] medications and this care plan was dated 1/25/17 and the interventions identified were .Monitor behaviors to assure lowest therapeutic dose given . A review was conducted of the medical records for the months of 6/17 through 8/17. The Medication Administration Record [REDACTED]. The MAR for 7/17 identified R#48 was administered [MEDICATION NAME] twice a day from 7/1/17 through 7/31/17. The quarterly Minimum Data Set (MDS) assessment dated [DATE], Section N for Medications identified R#48 was administered the antianxiety for the 7-day look back period. The MAR for 8/17 identified R#48 was administered [MEDICATION NAME] twice a day from 8/1/17 through 8/8/17. The Nursing Progress Notes were reviewed from the months of 6/17 through 8/17. There were no entries made that the resident was with or without anxiety during this time. An interview was conducted with Licensed Practical Nurse (LPN) BB on 8/8/17 at 3:46 p.m. LPN BB said if there were any changes in R#48's behavior that she would let the doctor know immediately. During this interview, the Staff Educator was present at the nursing station. At 3:56 PM the Staff Educator stated nursing staff knew the residents well and by definition the nurses will document by exception if there is a change in a resident's behavior. An interview was conducted with LPN EE on 8/9/17 at 7:43 a.m. LPN EE stated that R#48 is good at verbalizing her feelings to staff. She went onto state R#48's daughter is good at alerting the staff for any changes in the resident's behavior. An interview was conducted with the Director of Nursing (DON) on 8/10/17 at 8:25 p.m. When asked about R#48's monitoring of anxiety, the DON presented a document entitled .Hourly Monitoring . This document had columns (beginning from left to right) which identified the time, location, and initials of the staff members. The monitoring document began with a date of 5/15/17. Documented on this form was the location of R#48 and what R#48 was doing at the time of the observation. The DON said R#48's anxiety behavior was removing her safety alarms, going to the bathroom unassisted, getting herself into her wheelchair, and per the DON, R#48's is monitored every hour. The DON said nursing will also document by exception in the medical record regarding any changes in R#48's behavior. An interview was conducted with LPN CC on 8/10/17 at 8:38 a.m. LPN CC was presented with the documents entitled .Hourly Monitoring . and she stated that these documents were to monitor R#48's safety and they were not to monitor her anxiety. An interview was conducted with the Consulting Pharmacist on 8/10/17 at 11:21 a.m. The Consulting Pharmacist stated that he would expect that the nursing staff would be tracking signs and symptoms of anxiety and would look for this information in the clinical record. A facility policy entitled, Unnecessary Drugs and dated as revised 5/11, documented .Unnecessary Drug include any drug used .Without adequate monitoring . 2. Review of R#73's Patient Summary revealed the resident was admitted on [DATE]. The Coding Summary indicated the [DIAGNOSES REDACTED]. The Physician Orders from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the resident receiving [MEDICATION NAME] (an antianxiety) 0.5 milligrams (mg) 1/2 tablet twice a day since 6/4/14. The orders also indicated the resident received [MEDICATION NAME] (an antipsychotic) 0.25 mg twice a day. A review of R#73's record that included the progress notes, physician orders and medication administration orders revealed there were no attempts at gradual dose reductions since the medications were ordered. There was no documentation justifying the continued use of the medications. There were no care plans related to the use of the [MEDICATION NAME] and the [MEDICATION NAME]. There was no documentation in the record regarding the monitoring of behavior and mood. A review of the quarterly minimum data set (MDS) assessment dated [DATE] for R#73 Section D for Mood and Section [NAME] for Behaviors revealed the resident had no mood or behavior concerns documented. The quarterly MDS dated [DATE] revealed the resident had no mood or behavior concerns documented. An interview with the Director of Nursing (DON) on 8/10/17 at 8:15 a.m. verified there was no documentation regarding the effectiveness of the anti-anxiety and anti-psychotic medications. The DON verified there was no documentation of attempts at gradual dose reductions and no monitoring of moods and behavior for R#73. An interview with the pharmacist on 8/10/17 at 11:20 a.m. revealed the pharmacist had only been working for the facility for a month and was not able to respond to questions regarding the medication reviews and gradual dose reductions for R#73. 3. Review of the Face sheet revealed R#224 was admitted to the facility on [DATE]. A physician's admission order dated 7/18/17 for [MEDICATION NAME] (HCl) (an antidepressant) 25 milligrams orally each day lacked a [DIAGNOSES REDACTED]. R#224's History and Physical, dated 7/18/17, lacked a [DIAGNOSES REDACTED]. Observation of R#224 on 8/9/17 at 4:00 p.m. revealed resident in the wheelchair, visiting with family. R#224 smiled and showed no evidence of depressed mood. R#224 was later observed being pushed in the wheelchair by family, greeting staff and others present. Interview with Licensed Practical Nurse (LPN) HH on 8/9/17 on 8/9/17 at 4:10pm, confirmed the lack of [DIAGNOSES REDACTED]. LPN HH reported R#224 has not experienced symptoms of depression. LPN HH reported staff has knowledge of the residents' usual behavior and would report any changes to the physician promptly. The Consulting Pharmacist, interviewed by telephone on 8/10/17 at 10:00 a.m., acknowledged the completed Medication Review for R#224 was performed in July, (YEAR). The Consulting Pharmacist acknowledged he addressed other medication related concerns, but failed to identify the lack of a [DIAGNOSES REDACTED]. Review of the facility policy titled Unnecessary Medications revised 5/2011 directs Unnecessary drugs include any drug .without indications for its use . | 2020-09-01 |