cms_GA: 3889
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3889 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2018-08-26 | 759 | E | 0 | 1 | LV3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and facility policy review Administering Medications, the facility failed to ensure that the medication error rate was less than 5%. There were two errors with 32 opportunities for two of four residents (R) (R#38 and R#55) by one of two nurses observed, for a medication error rate of 6.25%. Findings include: 1.) On 8/25/18 at 8:21 a.m., Licensed Practical Nurse (LPN) CC was observed preparing R#38's medications, including one capsule of [MEDICATION NAME] (nerve pain medication and anticonvulsant) 100 milligram (mg). However, during further observation, the medication bag revealed to give 200 mg. At the end of preparing all 10 medications, the LPN agreed that was all that she was giving the resident at this time, and only one [MEDICATION NAME] capsule was prepared. Review of the Physician Order Report dated 7/25/18-8/25/18 revealed to give [MEDICATION NAME] 100 mg capsule, totaling 200 mg, twice a day (BID). Review of the Order Administration revealed that the last date the medication was administered was on 8/25/18 at 8:33 a.m. Interview with LPN, CC on 8/25/18 at 11:45 a.m., she confirmed that the resident takes 200 mg of [MEDICATION NAME]. Continued interview revealed that she was sure that she gave the resident 200 mg this morning and said that if there was an even number in his [MEDICATION NAME] bag then she did not give, but one. During interview, the LPN counted the medication with the surveyor and there was 18 pills in the [MEDICATION NAME] bag; however, unsure of the number in the bag at the start of the shift. After counting, the nurse said that if the package had an odd number in there then she only gave one and since there was an even number, she gave two capsules this morning. 2.) On 8/25/18 at 8:39 a.m., LPN CC, was observed preparing R#55's four medications, including Aspirin, Singular, [MEDICATION NAME], and [MEDICATION NAME]. At the end of preparing all four medications, the LPN agreed that was all she was giving the resident at this time. The surveyor saw the LPN only prepare and give R#55 four medication. However, at 8:55 a.m., the LPN, met the surveyor in the hallway, and said that when she was putting the resident's medication on a spoon and into his mouth, she counted five pills not four. She stated it was the resident's [MEDICATION NAME], but said she did not hand the medication bag to the surveyor to look at during the medication pass nor did she say anything about agreeing with it being in the medication cup at the time of the medication pass. Review of the Physician Order of Report dated 7/25/18-8/25/18 revealed Memantine 10 mg once a day and further review of the Order Administration revealed that Memantine 10 mg was last administered at 8:46 a.m. on 8/25/18. Interview with the Director of Nursing (DON) on 8/25/18 at 10:35 a.m., revealed that she did not expect that from this nurse and that she had just been observed by the pharmacist. Review of the facility policy Administering Medications with revised date of (MONTH) 2012 revealed that medications must be administered in accordance with the orders, including any required time frame; and the individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. | 2020-09-01 |