cms_GA: 38
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 38 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 759 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to ensure it was free of a medication error rate greater than five percent by not ensuring medications were given as ordered by physician for two residents (R) R#17 and R#54. A total of 29 medication opportunities were observed, and there were four errors for two of three residents (R) R#17 and R#54, by one of two nurses observed during medication pass, for a medication error rate of 13.79%. The census was 61 and the sample size was 40. Findings include: Review of the facility policy titled Medication Administration revised (MONTH) 2008 revealed under procedure number: 2: Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. Section C: Report any discrepancies to the pharmacy. Do not administer the mediation until the discrepancy is resolved. Observation of medication administration on 12/4/18 at 8:04 a.m. on side one, cart one, with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#54. The following observations were made: [MEDICATION NAME] (a medication used to hypertension) 25 milligram (mg) tablet, [MEDICATION NAME] (a medication used to treat acid reflux) 150 mg tablet, [MEDICATION NAME] (a medication used to treat depression) 10 mg tablet, [MEDICATION NAME] (a medication used to treat hypertension) 5 mg tablet, Calcium + vitamin D3 (a medication given as a supplement) 600/400 mg tablet and vitamin D3 (a medication given as a supplement) 1000 units, two tablets. After all of the R #54's 9:00 a.m. medications had been prepared, LPN EE counted the number of medications to be given, and verified during interview that what she prepared was all of the medications R#54 received for that time of day. During reconciliation with review of R#54 printed physician orders for the month of (MONTH) (YEAR) revealed the following orders: [MEDICATION NAME] 25 mg two times a day; vitamin D tablet 2000 unit, give two tablets one time a day; [MEDICATION NAME] 150 mg two times a day; [MEDICATION NAME] 5 mg two times a day; [MEDICATION NAME] 10 mg one time a day; Calcium-D 600/400 mg-unit one time a day. Licensed Practical Nurse (LPN) EE failed to administer R#54 the correct dosage of vitamin D3 per physician orders of 2,000 units, two tablets a day. Observation of medication administration on 12/4/18 at 8:25 a.m. on side one, cart one, with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#17. The following observations were made: Calcium + vitamin D3 (a medication given as a supplement) 600/400 milligram (mg) tablet one time a day, Duloxetine (a medication used to treat depression) 60 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 300 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat hypertension) 25 mg two times a day, [MEDICATION NAME] (a medication used to treat fluid retention) 20 mg two times a day, [MEDICATION NAME] (a medication used to treat acid reflux) 20 mg two times a day and [MEDICATION NAME] (a medication used to treat pain) 10 mg three times a day, Aspirin (a medication used as a blood thinner) 81 mg one time a day, Senna (a medication used as stool softener) 8.6 mg two tablets one time a day, Isorbide (a medication used to treat hypertension) 30 mg one time a day and Polyethylene [MEDICATION NAME] (a medication used to treat constipation) 17 grams (gm) one time a day. During reconciliation with review of R#17 printed physician orders for the month of (MONTH) (YEAR) revealed the following orders: Duplicated orders for [MEDICATION NAME] 10 mg three times a day, with scheduled administration times at 6:00 a.m, 2:00 p.m. and 10:00 p.m. and the duplicated order of [MEDICATION NAME] 10 mg three times a day, with administration times at 9:00 a.m., 1:00 p.m. and 9:00 p.m. The second duplicated medication order for [MEDICATION NAME] 20 mg two times a day, administration times at 6:00 a.m. and 4:00 p.m. and [MEDICATION NAME] 20 mg three times a day, with administration times at 9:00 a.m, 1:00 p.m. and 9:00 p.m. Interview on 12/4/18 at 10:36 a.m. with Registered Nurse (RN) BB, stated that night shift staff are responsible for verifying physician orders against Medication Administration Records (MAR). She stated that she checks every one of the MAR's herself for accuracy. She verified the orders fort R#17 for [MEDICATION NAME] 10 milligrams (mg) three times a day (TID) and [MEDICATION NAME] 10 mg TID and [MEDICATION NAME] 20 mg TID and [MEDICATION NAME] 20 mg two times a day (bid), to be duplicated orders. Interview on 12/4/18 at 10:50 a.m. with Licensed Practical Nurse (LPN) EE, who read the physician orders for R#54 Vitamin D3 to read 2000 units, give two tabs every morning. She immediately stated to the surveyor I only gave two tablets this morning. She asked surveyor if she could go give the additional two tablets? Interview on 12/4/18 at 12:10 p.m. with RN BB, stated that she had contacted R#17 Physician regarding clarification of two duplicated medications and clarification orders were obtained from physician to discontinue one of each of the duplicated orders. | 2020-09-01 |