cms_GA: 9546
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
9546 | JEFFERSONVILLE HEALTH & REHAB | 115413 | 113 SPRING VALLEY DRIVE | JEFFERSONVILLE | GA | 31044 | 2010-09-23 | 309 | D | 0 | 1 | 2O3N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to follow physician orders [REDACTED].#95, #8 and #12) from a sample of twenty-four (24)residents. Findings include: 1. Review of the Medication Administration Record (MAR) for resident # 95, revealed a current physician's orders [REDACTED]. There was no evidence that the medication was administered at 12:00 p.m. on 9/21/10.. During an interview with Licensed Practical Nurse "DD" on 09/22/10 at 8:30 a.m., she revealed that she had missed giving the medication for 09/21/10 at 12:00 p.m. 2. Review of the clinical record for resident #8 revealed a current physician's orders [REDACTED]. twice a day and at bedtime. Continued review revealed that on 6/29/10 a critically high [MEDICATION NAME] level of 38.8 mcg/ml (normal range 10 - 20 mcg/ml) was reported by the laboratory and the results were reported to the physician. On 6/30/10, the physician ordered that the medication be held for two (2) days. Review of the MAR for June and July 2010 revealed the day time medication was held but the evening dose for 6/30/10 and 7/01/10 was documented as administered to the resident. Further review of the clinical record revealed that on 9/13/10 a critically high [MEDICATION NAME] level of 36.7 mcg/ml was reported by the laboratory and the facility notified the physician. On 9/14/10 the physician ordered that the medication be held for three (3) days. Review of the MAR for September, 2010 revealed that again the daytime medication doses were held but the bedtime doses were documented as administered to the resident on 9/14, 9/15 and 9/16/10. Interview with the Director of Nursing (DON) on 9/22/10 at 10:30 a.m. revealed that the medication was documented as given contrary to the physician's orders [REDACTED]. 3. Review of the clinical record for resident #12 revealed that the resident was readmitted to the facility in March, 2010 with [DIAGNOSES REDACTED].. Review of the physician orders [REDACTED]. Review of the April, 2010 MAR revealed no evidence that the [MEDICATION NAME] had been administered as ordered. Interview with the DON on 9/22/10 at 3:30 pm revealed that at the end of each month,the nurses are to look at the physician's orders [REDACTED]. Further interview revealed that there was no evidence of an order for [REDACTED].. | 2015-06-01 |