cms_GA: 4056
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4056 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2019-09-26 | 759 | E | 0 | 1 | 2COK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and a review of the facility policy and procedure Medication Administration in DBHDD Hospitals, the facility failed to ensure the medication error rate was less than five percent (5%). There were two errors with 26 opportunities by two of three nurses observed which resulted in a medication error rate of 7.14%. Findings include: 1. On 9/25/19 at 7:45 a.m., Registered Nurse (RN) AA was observed giving R#16 his morning medications. The medications included Levetiracetam 100 milligrams (mg) / 2.5 milliliters (ml). After preparing all of the medications for R#16, RN AA verified she poured 2.5 ml in a liquid medication cup. A review of the Physician's Orders dated 9/12/19 revealed to administer Levetiracetam 100 mg/ml solution, 500 mg twice daily starting on 9/23/19. During an interview on 9/25/19 at 9:15 a.m., RN AA verified that she did not check the Medication Administration Record (MAR) and only went by the label instructions on the medication bottle which was for 2.5 ml twice daily. She confirmed that the label on the medication bottle did not match the current Physician Order An interview with the Nurse Manager on 9/25/19 at 9:56 p.m. revealed the medication nurses are responsible for checking the MAR prior to administering any prepared medications. 2. Observation on 9/25/19 at 11;58 a.m. of Licensed Practical Nurse (LPN) BB giving R#6 his medications. The medications included a multivitamin liquid suspension. After giving R#6 all of the medications via a [DEVICE], she confirmed she did not shake well the liquid multivitamin as per the manufacturer's instructions. An interview with the Nurse Manager on 9/25/19 at 12:45 p.m. confirmed that LPN BB did not follow the manufacturer's instructions or the facility's policy for the liquid multivitamin by not shaking it well prior to administration. A record review of the Medication Administration in DBHDD Hospitals reviewed and revised on 3/4/2019 revealed the following information: D. Medication Preparation 5. Liquid or suspension medications are shaken well (if not contraindicated) prior to measuring for administration. E. Medication Administration 2. The nurse reviews eMar or MAR and 24-Hour Support Plan (if apllicable), to identify medications to be administered along with consistency, texture, adaptive equipment, positioning, and other guidelines required for medication administration. 15. Medications are administered ensuring that the eight rights are maintained: a. Right Medication: Compare drug container label to the eMAR/MAR three (3) times (as described above). Note expiration date. Know action, dosage, and method of administration. Know side effects of the drug and any allergies [REDACTED]. An interview on 9/25/19 at 12:50 p.m. the Pharmacist revealed they were aware of the incorrect medication label for the Levetiracetam 100 mg/2.5 ml, administer 2.5 ml. The label should read 100mg/2.5 ml administer 5 ml. The pharmacist also stated that the liquid multivitamin is a suspension and requires to be shaken well prior to administering. An interview with the Administrator on 9/26/19 at 12:11 p.m. revealed his expectations of the nursing staff are to administer medications as ordered. | 2020-09-01 |