cms_GA: 92
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 92 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2017-11-08 | 514 | E | 1 | 1 | FY6A11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to ensure that the administration, justification, and effectiveness of PRN (as needed) antianxiety medication ([MEDICATION NAME] injection) was consistently documented on the Medication Administration Record (MAR) for five residents (R#6, R#137, R#138, R#201 and R#228) and vital signs were not recorded weekly, for one resident (#11), from (MONTH) (YEAR) until (MONTH) (YEAR). The resident sample was 35. Findings include: 1. Review of the Controlled Substance Accountability Sheet for R#6 revealed a pharmacy medication label with an original date of 5/23/17 for [MEDICATION NAME] INJ 2MG/ML (2 milligrams per milliliter) [MEDICATION NAME]- Inject 0.5 ML (0.25 ML). Review of the Physician order revealed no orders for [MEDICATION NAME] matching the pharmacy medication label. Review of the MAR revealed no order for [MEDICATION NAME] matching the pharmacy medication label, therefor, there was no documentation or evidence that [MEDICATION NAME] 0.25 ML injection had been administered to R#6. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist confirmed that R#6 does not have an order for [REDACTED]. The DON stated that the nurses should have noticed that there was no order for [MEDICATION NAME] and no order for [MEDICATION NAME] on the MAR. The DON further stated that the nurses should not have administered [MEDICATION NAME] to R#6, they should have notified the nursing supervisor and an order for [REDACTED]. The DON stated that the nurse receiving the telephone order is responsible for faxing the order to the pharmacy and entering the order into the electronic charting system, which in turn generates the order on the MAR. The DON stated she would have to find out who the nurse was that received the order. 2. Record review for R#137 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#137 revealed that [MEDICATION NAME] liquid injection was dispensed on 8/1/17 at 8:00 a.m. and 8:00 p.m., 8/2/17 at 4:00 a.m. and 7:35 p.m., 8/3/17 at 6:00 a.m., 9/23/17 at 5:00 a.m., 9/30/17 at 8:00 p.m., 10/1/17 at 4:30 p.m., 10/2/17 at 2:00 p.m., 10/4/17 at 6:00 a.m. and 7:35 p.m., 10/9/17 at 7:454 p.m., 10/11/17 at 6:00 a.m., 10/13/17 at 1:00 a.m., 10/19/17 at (no time), 10/22/17 at 6:00 p.m., and 10/28/17 at 3:00 a.m., 11:00 a.m., and 1:00 p.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] was administered on these dates. 3. Record review for R#138 revealed a Physician's order start date 11/30/16 for [MEDICATION NAME] Solution 2 MG/ML (two milligram per milliliter), Inject 1 MG subcutaneously as needed for unspecified [MEDICAL CONDITION] anxiety, give every six hours PRN (as needed) agitation. Review of the Controlled Substance Accountability Sheet for R#138 revealed 0.5 ML of [MEDICATION NAME] was dispensed on 8/11/17 at 10:00 a.m. and 6:00 p.m., 10/15/17 at 10:00 a.m., 10/16/17 at 2:00 a.m., 10/22/17 at 10:00 a.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] injection was administered on these dates. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist confirmed that documentation on the MAR for R#138 was not consistently conducted by the nurses in correlation to the [MEDICATION NAME] dispensed on the Controlled Substance Accountability Sheet. The DON stated that all medications are to be documented on the MAR. 4. Record review for R#201 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#201 indicated that [MEDICATION NAME] liquid injection was dispensed on 9/10/17 at 6:00 p.m., 9/13/17 at 11:00 a.m., 9/14/17 at 2:00 p.m., 9/22/17 at 9:00 a.m. and 2:00 p.m., 9/29/17 at 11:00 p.m., 10/2/17 at 2:00 a.m. and 10/31/17 at 10:00 p.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] was administered on these dates. Interview on 11/3/17 at 3:45 p.m. with LPN GG revealed that she personally has never administered [MEDICATION NAME] injection for R#201 but it is expected to not only document on the substance control sheet but to execute it on the MAR at the time given, to select the code for justification and also document in the nurse's notes. 5. Record review for R#228 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#228 revealed [MEDICATION NAME] liquid injection was dispensed on 8/17/17 at 4:00 a.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] was administered on this date. Interview on 11/3/17 at 6:07 p.m. with LPN EE revealed when she administers a narcotic medication, she is expected fill the out the substance control sheet with the date and time, dosage, number of single vials, wasted mount with another nurse/witness. LPN EE further stated she would document in the nurse progress notes and the MAR. On the MAR she must pick the justifying code for administration and it is supposed to be done right then when the narcotic was given not later. LPN EE stated the computer captures the time of entry and alerts the nurse to document the effectiveness. 6. Review of the facility Policy titled Physician Orders policy, dated (MONTH) 2011, indicated the licensed nurse receiving the order verifies the order to ensure it is complete and that it includes: accurate dosage, accurate frequency and duration as applicable. Further review of the Physician Orders policy indicated a physician's order is required prior to the discontinuation of any current order. R#11 was re-admitted to the facility on [DATE], after a hospitalization for an acute [MEDICAL CONDITION]. The resident had the following [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. Record review of the hospital discharge Physician orders, dated 5/4/17, and handwritten orders with the same date signed by Registered Nurse (RN) KK and signed by the Nurse Practitioner (NP), revealed the resident had the following orders for treatment of [REDACTED]. Review of the electronic Physician Orders dated 5/4/17, signed by RN KK, revealed an order for [REDACTED].>[MEDICATION NAME] 0.1 milligrams (mg)-two tablets-three times per day-for three days only although the orders were signed by the NP. Review of the electronic Medication Administration Record (MAR) for May, June, (MONTH) and (MONTH) (YEAR) the resident's vital signs should be taken and recorded weekly. Further review revealed the resident's vital signs were taken although were not recorded in the record. An interview with RN KK and the Director of Nursing on 11/3/17 at 4:42 p.m. revealed that two nurses review the admission orders [REDACTED]. Review of the computer generated Physician's orders dated 5/4/17 are signed only by RN KK. The DON further revealed that this process, of having two nurses confirm the Physician orders, was not in place until after this error was identified by the surveyor. RN KK revealed that she made an entry error for the [MEDICATION NAME] which was not identified until the survey began on 10/18/17. Interview and review of the electronic Medication Administration Record (MAR), supplied by the DON on 11/8/17 at 6:00 p.m., for June, (MONTH) and (MONTH) (YEAR) revealed that the resident's blood pressure should be taken and recorded weekly since 5/4/17. Review of the MAR revealed a check that the blood pressure was taken although there is no evidence of the results for June, (MONTH) and (MONTH) (YEAR). The DON confirmed that staff did not document the resident blood pressure from (MONTH) 8, (YEAR) until the resident became symptomatic in (MONTH) (YEAR). | 2020-09-01 |