cms_GU: 54
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
54 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2014-09-19 | 514 | D | 0 | 1 | OCYD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, and the facility failed to ensure that all verbal and telephone orders obtained related to the urgent or emergent situations, and that all clinical records were legible, dated, timed, and signed. Persistent over use of verbal and or telephone orders, that are handwritten or re-transcribed on the monthly basis, has the potential for increased transcription error. Findings include: 1. On 9/19/14 the medical records for Residents 1 and 3 were reviewed with a licensed nurse (LN4). The nurse acknowledged that the monthly reoccurring orders for Resident 1 for the months of (MONTH) and (MONTH) 2014 were telephone orders. The records reflected that there were five physician's orders [REDACTED]. LN 4 acknowledged that the following orders were possibly not related to an emergent or urgent situations: [MEDICATION NAME] 100 milligrams orally two times a day; and [MEDICATION NAME] cream to hemorrhoids two times a day as needed. 2. Resident 3 was admitted on [DATE] with hand written telephone orders. Between 8/23/14 to 8/26/14, there were 8 physician's orders [REDACTED]. 3. On 9/19/14, the Guam Memorial Hospital Authority Nursing Services Manual addressing Physician order [REDACTED]. The policy indicated, All physician orders [REDACTED]. Additionally, The policy reflected Use of verbal and telephone orders must be minimized in all nursing units. Verbal or telephone orders must be taken by an RN only. Use of verbal orders must be limited to urgent and emergent situations 4. Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The resident was also noted as having a right below-knee amputation and described in the initial minimum data set ((MDS) dated [DATE] as having no cognitive impairments and dependent on staff for most activities of daily living with one-person physical assist. Review of the medical record revealed that the resident had a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. elevated temperature), or result or effect, if any, after the medication was given. | 2019-04-01 |