cms_GA: 9722
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9722 | KINDRED TRANSITIONAL CARE AND REHAB - LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2012-01-26 | 333 | J | 1 | 0 | 5SCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, hospital Discharge Summary review, review of the facility's Policy/Procedure for Verbal/Telephone Orders, National Library of Medicine reference information review, facility staff interview, attending physician interview, and physical therapist interview, the facility failed to ensure that each resident was free of any significant medication errors by failing to administer potassium chloride (KCL) in accordance with the physician's orders [REDACTED].#1), of (9) residents on the survey sample who received KCL therapy, and by failing to administer [MEDICAL CONDITION] medication [MEDICATION NAME] in accordance with the physician's orders [REDACTED].#2), on the total survey sample of sixteen (16) residents. Resident #1, who was ordered to received two (2) doses of KCL 40 milliequivalents (mEq), was administered four (4) additional doses of the drug and subsequently died after a laboratory test indicated a critical potassium level. Based on the above, it was determined that the facility's failure to administer KCL as ordered by the physician had caused serious harm to, and contributed to the death of, Resident #1. It was therefore determined that the facility's noncompliance with one or more requirements had resulted in an immediate and serious threat to resident health and safety which was identified to have existed on [DATE] and continued through [DATE], at which time a plan was implemented by the facility to remove the immediate jeopardy situation as of [DATE]. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on [DATE] at 1:55 p.m. Findings include: 1. Review of the facility's Policy/Procedure for Verbal/Telephone Orders, dated as having been last revised on [DATE], revealed a heading which read "Caution: Following the procedure below is very important to prevent confusion, medication errors and maintain communication between the disciplines." Part 2 of the Procedure specified to record the physician's orders [REDACTED]. Record review for Resident #1 revealed a hospital Discharge Summary dated [DATE] which documented that Resident #1 had been admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital physician documented that the resident was sitting up in a chair, followed commands, and moved all extremities. The hospital physician also documented that the resident had worked with physical therapy (PT) and occupational therapy (OT) and would be discharged to the nursing facility for rehabilitation. A Resident Progress Notes entry dated [DATE] at 1:30 p.m. documented Resident #1 arrived at the nursing facility, and that the resident was alert upon admission and was able to ambulate to the bathroom with the assistance of one. A Physical Therapy Evaluation dated [DATE] documented that the resident had resided in a personal care home prior to hospitalization . The physical therapist documented that the resident needed stand-by assistance with ambulation, and presented with generalized weakness following hospitalization . The therapist further documented that the resident presented for skilled physical therapy to address the generalized weakness and balance deficits for return to the prior living situation, and with the patient/family goal of returning home. A Daily Patient Services Record documented that on [DATE], the resident began receiving skilled physical therapy services. During an interview with the physical therapist on [DATE] at 1:10 p.m., who had provided physical therapy services to Resident #1, this physical therapist stated that although the resident was weak from dehydration and being in the hospital, once admitted to the nursing facility the resident was ambulating and had made significant progress toward the goal to return to the assisted living setting. The physical therapist stated that it was the plan for the resident to return to the prior living setting. A Resident Progress Notes entry dated [DATE] at 9:00 a.m. documented that the resident had ambulated to the bathroom with assistance of one, responded well to all verbal stimuli, and had attended the facility church services that morning. Review of a Laboratory Report, with a draw date and time of [DATE] at 3:25 a.m., revealed a Basic Metabolic Profile (BMP) which documented Resident #1 to have a low potassium level of 3.3 millimoles per liter (mmol/L), with a reference range listed as 3.5 - 5.0 mmol/L. A Resident Progress Notes entry of [DATE] at 11:00 p.m. documented that physician's orders [REDACTED].#1, signed by Licensed Practical Nurse (LPN) "DD", specified an order to administer KCL forty (40) mEq by mouth every four (4) hours times two (2) doses, and also specified a BMP laboratory test to be done on [DATE]. However, review of the [DATE] Medication Record (MR) for Resident #1 revealed that the physician's orders [REDACTED]. Further review of this MR revealed documentation indicating that Resident #1 received 40 mEq. doses of KCL at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. on [DATE], and at 1:00 a.m. and 5:00 a.m. on [DATE]. Thus, Resident #1 received a total of six (6) 40 mEq doses of KCL, instead of two (2) doses as ordered by the physician. Resident Progress Notes entries of [DATE] at 9:00 a.m. and 9:00 p.m., and [DATE] at 9:00 a.m., documented that Resident #1 had remained alert during this period of time while she had been receiving, in error, these excess doses of KCL 40 mEq. However, a Laboratory Report for Resident #1, with a draw date and time of [DATE] at 4:30 a.m., which was approximately the same time the resident received the final dose of KCL, documented the results of a BMP laboratory test which indicated that the resident's potassium level was critically high at 8.2 mmol/L (Reference Range, 3.5 - 5 mmol/L). A notation on this Laboratory Report documented that this "Critical Value" had been called to a nursing facility nurse on [DATE] at 12:30 p.m.. A subsequent Resident Progress Notes entry of [DATE] at 2:00 p.m. documented that the nurse had been summoned to the room of Resident #1 by a certified nursing assistant, and that the resident was observed by the nurse to be non-responding to verbal stimuli, and to have no respirations, no blood pressure, and no pulse. A Resident Progress Notes entry of [DATE] at 7:20 p.m. documented that the body of Resident #1 had been released to the funeral home. During an interview conducted on [DATE] at 9:00 a.m. with the Director of Nursing (DON), the DON acknowledged the medication error involving potassium drug therapy for Resident #1. During an interview with Resident #1's attending physician conducted on [DATE] at 9:50 a.m., the physician stated that she had actually been present in the facility when the critical potassium laboratory value report was called to the facility. The physician stated she had then gone to examine the resident and had assessed the resident to be unresponsive. The physician stated she had called the resident's family to notify them of the resident's high potassium level, at which time the family member stated she would call the physician back. The physician stated that before the family member returned the call, the resident had expired. The physician stated that this medication error involving the administration of potassium had been a contributing factor in the resident's death. Based on the above, the facility failed to administer KCL 40 mEq every 4 hours for 2 doses to Resident #1 as ordered by the physician, but rather administered KCL 40 mEq every 4 hours for a total of six (6) doses, in error. The resident was subsequently determined to have a critically elevated potassium level of 8.2 mmol/L, became unresponsive and died . 2. Record review of Resident #2 revealed an entry on the [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Resident Progress Notes entry of [DATE] at 10:30 a.m. documented that the resident's [MEDICATION NAME] was supplied by the family. Review of the National Library of Medicine, National Institutes of Health reference for [MEDICATION NAME] revealed that the medication is used to treat certain types of [MEDICAL CONDITION] by blocking [MEDICAL CONDITION] cells from multiplying. The [DATE] MR for Resident #2 indicated that the resident was to receive a [MEDICATION NAME] 150 mg. capsule twice a day via gastrostomy tube at 10:00 a.m. and 10:00 p.m. for the [DIAGNOSES REDACTED]. A [DATE] entry by the evening nurse in the Nurse's Medication Notes Section of this MR documented that this medication was not available at that time, and that the family would bring the medication in the following day. However, further record review conducted on [DATE] revealed no evidence to indicate that the resident had received additional doses of [MEDICATION NAME] at that time, even though the order specifying administration of the drug remained current. There was also no evidence to indicate that the facility had made additional efforts to obtain the resident's [MEDICATION NAME] for administration, nor was there evidence to indicate the attending physician had been notified that the resident had missed multiple doses of [MEDICAL CONDITION] medication. During an interview on [DATE] at 11:20 a.m., the DON stated she had no knowledge that the resident's [MEDICATION NAME] had not been administered as the physician ordered. The DON reviewed the MR at that time and acknowledged that the medication had not been given as ordered. The DON obtained the package container for the resident's [MEDICATION NAME], and confirmed that it was empty and that there was no medication available. During an interview conducted on [DATE] at at 9:40 a.m. with the attending physician, the physician indicated she had no knowledge that Resident #2 was not receiving the ordered medication [MEDICATION NAME]. The physician stated that the medication should be given as ordered, and if unavailable, the physician should be notified. Record review revealed that after the physician's interview referenced above, an order was written to hold Resident #2's [MEDICATION NAME] until available. Evidence thus indicated that Resident #2 missed a minimum of five (5) doses of [MEDICATION NAME], ordered to be given twice daily, due to the medication not being available, during which time the facility failed to notify the physician for further instructions. It was determined that the immediate jeopardy was removed as of [DATE], by which time the facility had completed the following actions. Beginning on [DATE], and continuing through [DATE], the following corrective interventions were being taken by the facility to ensure accurate medication administration: I. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education on medication errors and verbal/oral telephone orders. The education included face-to-face training on the validation of telephone orders; monitoring of laboratory values; medication effects of high risk medications such as Potassium, [MEDICATION NAME], and Insulin; clarification of medication orders with the physician and/or nurse practitioner; signs of hypo/[MEDICAL CONDITION]; and the policy and procedure for verbal/telephone orders, hand written orders, written transfer orders or faxed orders. II. On [DATE], a process was begun by which newly hired licensed nurses will be educated during the orientation process that will be conducted by the DON, Assistant Director of Nursing (ADON), and/or Staff Development Coordinator. III. On [DATE], the licensed nurse who transcribed the KCL order for Resident #1 was removed from the work schedule and suspended pending the results of investigation by the Georgia Board of Nursing. IV. On [DATE], the Performance Improvement Committee met to address the adverse event and discuss appropriate interventions. The committee consisted of the Administrator, Medical Director, DON, the Admissions Coordinator and the Corporate Risk Manager. V. On [DATE], a process was begun by which new admissions, re-admissions and revised medication orders will be reviewed by the admitting licensed nurse and a second verification will be performed by a registered nurse to assure validity and accuracy of medication orders. The DON, ADON, and Unit Managers will perform a third verification of medication orders to assure validity and accuracy in the Clinical Morning Meeting at least five (5) times a week. The Nursing Supervisor and/or Charge Nurses will be responsible for reviewing and validating new admissions, re-admissions, and revised orders on the weekend. Negative findings through this process will be corrected immediately through physician and/or nurse practitioner notification, and discontinuance of inaccurate medication orders will occur immediately. The institution of the correct transcribed medication order to the telephone order sheet, MR and medical record will be documented as outlined by the policy and procedures. A Medication Variance Report will be completed by the Unit Managers and/or the DON or ADON when medication inaccuracies are identified through this newly adopted, systematic change. This process will be on-going. VI. On [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review. The results of these audits will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. A subsequent plan will be devised and implemented as needed. This process will be ongoing. VII. On [DATE], a complete review and audit of all resident clinical records was completed by the DON, ADON, and Unit Managers. This review and audit included comparing physicians' orders and telephone orders to the transcribed medication orders on the MRs. VIII. On [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received inservice education on medication errors and verbal/written/oral telephone orders, as described above. IX. On [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, and four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, received additional inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. In addition, two (2) licensed practical nurses and two (2) registered nurses, with no documented attendance in either of the previous inservice training sessions, received training on this date. Based on these corrective action plans which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice had been removed on [DATE]. However, the effectiveness of these corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], four (4) registered nurses and fifteen (15) licensed practical nurses received inservice education including medication errors and verbal/oral telephone orders, and on [DATE], two (2) registered nurses and twenty-seven (27) licensed practical nurses received this inservice education. However, on [DATE], ten (10) of the licensed practical nurses and three (3) of the registered nurses who had originally received the [DATE] inservice training referenced above, four (4) of the licensed practical nurses and one (1) registered nurse who had received the [DATE] inservice training referenced above, and two (2) licensed practical nurses and two (2) registered nurses with no documented attendance in either of the previous inservice training sessions, received additional or initial inservice training on medication errors, medication transcription, medication administration records, and treatment administration records. Also, on [DATE], a process was enacted by which the DON, and/or ADON, and/or Unit Managers will audit new admissions, re-admissions and medication orders in daily clinical review, the results of which will be analyzed and reviewed at the facility's monthly Performance Improvement Committee meetings for six months. However, the first meeting of the Performance Improvement Committee to occur after the implementation of the new monitoring procedures and chart audit procedure to begin the process of analyzing the audit did not occur until [DATE], and the committee will not meet again for a month. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level. | 2015-05-01 |