cms_GA: 88
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 88 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 425 | D | 1 | 1 | FY6A11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility's Dispensing Pharmacy failed to ensure an accurate dosage on the pharmacy medication label for one resident (R#201) that received Ativan liquid injection and failed to ensure that Physician orders [REDACTED]. orders [REDACTED].#137 and R#201). The resident sample was 35. Findings include: 1. Record review for R#137 revealed a physician's orders [REDACTED]. Review of the medication pharmacy label on the plastic bag containing vials of Ativan 2MG/ML, prescribed to R#137 indicated Inject Intramuscularly 1 vial every eight hours. Interview with the Consulting Pharmacist (CP) on 11/3/17 at 1:55 p.m. revealed she does conduct random audits and selects random medication carts. She stated she checks the control sheet for narcotics and ensures that the medication count matches what is on the control sheet. The CP further stated she does check the narcotics in the medication storage refrigerators but only to check for expiration dates and the correct amount of medication. She stated she does not check for the accuracy of the pharmacy label to ensure that it matches the facility's Physician order. Interview on 11/3/17 at 5:00 p.m. with the Dispensing Pharmacist (DP) revealed that narcotic medications orders have to be reordered after six months. He stated the order for Ativan 1 MG injection previously prescribed for R#137 on 3/28/17 could no longer be filled. He stated the pharmacy received an order directly from the physician's office on 10/27/17 for Inject Intramuscularly 1 Vial every 8 hours quantity five and five remaining. The DP stated the facility would have to call for the remaining five vials. The DP stated the prescription does not read PRN (as needed). The DP stated there are several dispensing pharmacist and per the system notes, the pharmacist called the facility and documented that the prescription was reported to LPN KK and two other staff names. The DP stated that no last names were documented in the notes and he is unable to confirm if the actual prescription was faxed to the facility. Interview on 11/3/17 at 6:42 p.m. with Unit Manager LPN KK revealed that the prescription for IM Ativan for R#137 had expired so she called the Physician's office and asked them to send a new prescription. The Nurse at the Physician's office stated that she sent a prescription for IM Ativan directly to the pharmacy. LPN KK stated that the Pharmacy then called to clarify the order and she was telling them not to send multi dose vials and to send the 1ML vials. The Pharmacy asked her to call the physician's office back for a new prescription for a single dose vial. LPN KK called the Physician's office back and they stated that were faxing it to the pharmacy right then. LPN KK stated that she expected the order to be the same exact order for Ativan as he had been on for months and the only thing she wanted to make sure is that they send a single dose 1ML vials. LPN KK stated she did not request the new prescription from the pharmacy because it was a renewal. LPN KK stated they did not tell her that the prescription was a change from the previous prescription and they never faxed her the new prescription. LPN KK stated that the nurse should have compared the pharmacy label to the Medication Administration Record [REDACTED]. 2. Record review for R#201 revealed a physician's orders [REDACTED]. Review of the medication pharmacy label on the plastic bag containing vials of Ativan 2MG/ML, prescribed to R#201 indicated Inject 1 MG (0.25ML) IM every four hours as needed with original date of 8/29/17. Interview on 11/3/17 at 5:30 p.m. with the Dispensing Pharmacist (DP) revealed that the prescription order with an original date o 8/29/17 with the medication label that indicates Lorazepam INJ 2MG/ML, Inject 1MG (0.25ml) is a pharmacy error. The DP stated that the correct dosage for 1MG would be 0.5ML, not 0.25ML. The DP stated that the pharmacy technician receives an order and enters the order into the system. The Pharmacist is responsible for checking all orders for accuracy of dates, names, dosages etc. then the pharmacist checks a box indicating that he reviewed the medication. An electronic signature is captured when this box is checked. The DP stated that this check system is only conducted when an order first comes in, not with each refill. The DP further stated that the receiving Pharmacist called the physician's office and clarified that the order should be for 1MG (0.5ml). The DP stated that he could not find documentation in the system notes or fax documentation that the facility was notified when the prescription was changed from the original order. The Pharmacist stated when the currier delivers medications, the facility nurse will reconcile the medication from the manifest sheet to the medications actually in the tote. | 2020-09-01 |