cms_ID: 19
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 19 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2018-10-12 | 758 | E | 0 | 1 | SC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy and procedure review, it was determined the facility failed to ensure a.) residents' behaviors and potential side effects of [MEDICAL CONDITION] medications were routinely monitored b.) there was a clear indication for use of PRN [MEDICAL CONDITION] medication c.) non-pharmacological approaches were attempted prior to the use of PRN medications d.) physician orders for PRN antianxiety medications were time limited and e.) residents received PRN [MEDICAL CONDITION] medications only when clinically indicated for the treatment of [REDACTED].#5, #7, #9, #10, #11, #12, and #64) reviewed for unnecessary medications. This created the potential for harm should residents receive [MEDICAL CONDITION] medications that were unnecessary, ineffective, or used for excessive duration, and placed them at risk for adverse reactions from [MEDICAL CONDITION] medications. Findings include: The facility's policy for Medication Use in Long Term Care, revised 4/25/18, documented psychoactive medications are prescribed when necessary to treat specific medical conditions. When prescribed: * The [MEDICAL CONDITION] medications will have a documented indication for the medication in the medical record. * Psychoactive MEDICATION ORDERS FOR [REDACTED]. If there is a continued clinical need the prescriber will document in the medical record justification for continued use. * Each behavior monitoring record will identify the specific symptoms for which the drug is being used. The documentation of the behavior will be quantitative and objective. * Each resident will have care plan interventions specific to their mood, behavior, and activity. * Pharmacy medication regimen review will evaluate prescribed medications orders for an adequate indication for use, appropriateness of ongoing therapy, medical necessity, adverse drug reaction and side effects, and adequate monitoring of therapy. 1. Resident #12 was admitted to the facility on [DATE], with multiple diagnosed including: [DIAGNOSES REDACTED]. A physician's Inpatient Progress Note, dated 9/13/18, documented Resident #12 had a [DIAGNOSES REDACTED]. Resident #12's admission MDS assessment, dated 9/19/18, documented she was severely cognitively impaired, had moderately severe depression, exhibited behavioral symptoms not directed toward others, and received antipsychotic medications and antianxiety medications daily. Resident #12's physician orders, dated 10/5/18, directed staff to provide [MEDICATION NAME] (antipsychotic) 1 mg by mouth nightly and [MEDICATION NAME] (antidepressant/sedative) 50 mg nightly. The physician orders did not include the [DIAGNOSES REDACTED]. A care plan, dated 10/11/18, identified mood/behaviors and dementia with behavioral symptoms for Resident #12 and directed staff to monitor for side effects related to her antipsychotic medication. The care plan documented she could become tearful and bang her fist on the table because she could not live at home with her husband. The care plan did not provide specific behaviors for [DIAGNOSES REDACTED]. Resident #12's Care Plan did not identify [MEDICAL CONDITION]. There was no documentation in Resident #12's record her sleep was monitored. On 10/13/18 at 10:15 AM, the DON stated the facility did not monitor Resident #12's hours of sleep. 2. Resident #5 was admitted to the facility on [DATE], with multiple diagnosed including: [DIAGNOSES REDACTED].) Resident #5's annual MDS assessment, dated 8/21/18, documented she had moderately impaired cognition, had mild depression, exhibited delusional thoughts, verbal behavioral symptoms directed toward others, and received antianxiety medications daily. Resident #5's physician orders, dated 7/13/18, directed staff to provide [MEDICATION NAME] 0.5 mg by mouth nightly and 0.25 mg every morning. On 8/23/18, an order for [REDACTED]. The physician orders did not include the [DIAGNOSES REDACTED]. Resident #5's MAR indicated [REDACTED]. The PRN order for [MEDICATION NAME] documented This is an extra dose when she needs it. Resident #5's care plan, dated 5/22/18, documented interventions for sundowning behaviors, agitation, and [MEDICAL CONDITION]. The care plan documented the antianxiety medication was to help with Resident #5's worries she experienced over her children and family. The care plan did not identify specific behaviors exhibited by Resident #5 related to her anxiety. A Mood/Behavior of Cognitively Impaired care plan, dated 10/9/18, directed staff to monitor for side effects related to antianxiety medications. A Behavioral/Psychopharmacological Review, dated 9/6/18, documented Resident #5 received [MEDICATION NAME] 0.5 mg two times daily and 0.5 mg daily as needed. The review documented Resident #5's targeted behaviors were delusions, hallucinations concerning family and/or children, yelling at/threatening staff, residents, and visitors, wandering, exit seeking, and crying/yelling for help. Resident #5's Behavior Monitoring flowsheets, dated 7/14/18 through 10/11/18, documented Resident #5 exhibited disorientation, anxiety, was unwilling to follow instruction, yelling, screaming, restless, fearful, resistive to care, multiple requests, crying, and tearful. Resident #5's behavior monitoring did not indicate whether medications were given, what the indications were, what behaviors were being monitored, or why Resident #5 received the additional [MEDICATION NAME] or the effectiveness of the anti-anxiety medication. The documentation did not provide non-pharmacological interventions for staff to attempt prior to providing the PRN dose of [MEDICATION NAME]. The targeted behaviors identified for monitoring on the Behavioral/Psychopharmacological Review were inconsistant with the behaviors exhibited on the behavior monitoring. On 10/11/18 at 3:30 PM, the DON and RCA stated the medication was for anxiety but could not identify the specific behaviors exhibited. 3. Resident #64 was admitted to the facility 10/1/18, with multiple diagnosed including: [DIAGNOSES REDACTED]. Resident #64's admission MDS assessment, dated 10/1/18, documented she was cognitively intact, had mild depression, had no behaviors, and received antidepressant medication daily and antianxiety medications almost daily, 5 out of 7 days. Physician orders, dated 10/1/18, documented Resident #64 was to receive [MEDICATION NAME] (an antidepressant) 20 mg by mouth daily, [MEDICATION NAME] (a mood stabilizer) 100 mg by mouth daily, and [MEDICATION NAME] (an antianxiety medication) 0.5 mg by mouth 3 times daily as needed. The orders did not include a [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A care plan, dated 10/11/18, documented Resident #64 had major [MEDICAL CONDITION] and was prescribed an antidepressant medication. The care plan documented the activities Resident #64 enjoyed and the common side effects of the medication, however, the care plan did not indicate the behaviors exhibited due to depression. The care plan did not address the [MEDICATION NAME] or the [MEDICATION NAME]. Resident #64's Behavior Monitoring flowsheet included sections to document whether she was able to express her needs, her feelings, her thoughts, and her ability to understand. The entries, from 10/1/18 through 10/11/18, documented Resident #64 was calm, cooperative, able to express her feelings, needs, thoughts, and understood others. Resident #64's behavior monitoring flowsheet did not include what medications were given, what the indications were, what behaviors were being monitored, and how many episodes were exhibited each shift. The monitoring flowsheet also did not include why Resident #64 requested [MEDICATION NAME] or the effectiveness of the medication. On 10/11/18 at 3:30 PM, the DON stated Resident #64 was cognitively intact and would request the [MEDICATION NAME] when she needed it. The DON stated the staff did not ask Resident #64 the reason she was requesting the antianxiety medication. 4. Resident #11 was admitted to the facility on [DATE], with multiple diagnosed including: [DIAGNOSES REDACTED]. Resident #11's Significant Change MDS assessment, dated 9/13/18, documented severe cognitive impairment, mild depression, hallucinations, she received antipsychotic and antidepressant medications daily. Resident #11's physician orders directed the staff to provide [MEDICATION NAME] (an antipsychotic) disintegrating tablet 15 mg by mouth nightly and [MEDICATION NAME] (an antidepressant) 20 mg by mouth daily. The orders did not provide a [DIAGNOSES REDACTED]. Resident #11's care plan, dated 5/29/18, documented a [DIAGNOSES REDACTED]. The care plan documented Resident #11 was taking medication to help with the delusions and hallucinations. A Mood/Behavior of Cognitively Impaired care plan, dated 10/9/18, directed staff to monitor for side effects related to antianxiety medications. A monthly Long-term Care Pharmacy Review, dated 6/15/18, documented Resident #11 continued to see worms and spiders in her food, picked bugs off her clothing and the floor, saw men in her room and talked with people that were not present. A monthly Long-term Care Pharmacy Review, dated 8/14/18, documented Resident #11's fear and paranoia were improved and her fear of men, paranoia, delusions, and hallucinations were improved with the combination of the antidepressant and antipsychotic medications. A monthly Long-term Care Pharmacy Review, dated 9/12/18, documented Resident #11's fear of men, paranoia, delusions, and hallucinations were improved with the combination of the antidepressant and antipsychotic medications. A Behavioral/Psychopharmacological Review, dated 9/6/18, documented Resident #11 received [MEDICATION NAME] 5 mg nightly and [MEDICATION NAME] 20 mg daily. The review documented Resident #11 continued to experience mild hallucinations but none that prevented care and nutrition as before. The facility's Behavior Monitoring flowsheet documented whether Resident #11 was able to express her needs, her feelings, her thoughts, and her ability to understand. The entries completed each shift, from 7/14/18 through 10/11/18, documented Resident #11 was calm, cooperative, able to express her feelings, needs, thoughts, and understood others. The Behavior Monitoring flowsheet did not document episodes of hallucinations or delusions. The behavior monitoring did not indicate what medications were given, what the indications for the medications were, what behaviors were being monitored, how many episodes were exhibited each shift, or provide non-pharmacological interventions to staff. On 10/11/18 at 3:30 PM, the DON stated that Resident #11 has continued to have hallucinations and delusions but they are not upseting to her now. 5. Resident #7 was admitted to the facility on [DATE], with diagnoses which included dementia with behavioral disturbance, Type II DM, HTN, and a history of stroke. An H&P, dated 8/28/18, documented Resident #7 was living in an Assisted Living Facility when she was sent to the local ER due to combativeness, striking other residents at the facility. Resident #7 was admitted to the hospital and subsequently admitted to the facility. The H&P stated Resident #7's combativeness continued at the hospital and she was treated with [MEDICATION NAME] 75 mg twice daily. The note documented the plan was to ensure the combativeness was well controlled and then attempt a reduction in the dose of [MEDICATION NAME]. A physician progress notes [REDACTED].#7 had not demonstrated behaviors which were a challenge to staff previously. The physician documented a plan to initiate a gradual medication reduction of [MEDICATION NAME] beginning 9/3/18. The MAR indicated [REDACTED]. On 9/3/18, Resident #7 received 2 routine doses of [MEDICATION NAME] 50 mg and a 1 time dose of 50 mg, a total of 150 mg. Resident #7's [MEDICATION NAME] dose was reduced on 9/3/18, however, she received an additional 1 time dose on that day, which equaled her original dose. On 9/4/18, Resident #7's [MEDICATION NAME] was increased back to 75 mg twice a day. The physician's plan to initiate a gradual medication reduction of [MEDICATION NAME] was not documented after the attempt on 9/3/18. Resident #7's care plan, dated 9/7/18, identified the need for management of her behaviors related to her dementia. The care plan documented Resident #7 may become physical when she is upset, banging her fist on the wall, or yelling at others. It also stated Resident #7 may become frustrated and angry when her daughter and/or husband leave without her after a visit, it is too noisy, or she believes people are lying to her. Interventions included redirection to another activity which involved music or games, removing Resident #7 from other residents if she was yelling at them, or have a staff member sit and talk quietly with her in a quiet place. Resident #7's record included a Behavior Monitoring flowsheet. The flowsheet included sections for documentation of the date and time, resident behaviors, expressed needs, the ability to express feelings, needs, and thoughts, and the resident's ability to understand others. The flowsheet for Resident #7 was dated 8/28/18 to 10/11/18. Staff entries varied from 1 to 5 times a day. The Behavior Monitoring flowsheet included the following: - On 8/30/18 at 6:38 PM, Resident #7's behavior was described as angry, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger. There was no documentation of interventions by staff. - On 9/1/18 at 3:00 PM, Resident #7's behavior was described as restless and impulsive. There was no further description of her behaviors. There was no documentation of interventions by staff. - On 9/2/18 at 10:00 AM, Resident #7's behavior was described as Cries/tearful. There was no further description of her behaviors. There was no documentation of interventions by staff. - On 9/5/18 at 5:00 PM, Resident #7's behavior was described as Anxious; Resistive to care; Restless. There was no further description of her behaviors. There was no documentation of interventions by staff. - On 9/8/18 at 6:34 PM, Resident #7's behavior was described as Angry; Anxious, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger. There was no documentation of interventions by staff. - On 9/10/18 at 6:49 PM, Resident #7's behavior was described as Anxious; Angry; Cooperative, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger or anxiety. There was no documentation of interventions by staff. - On 9/17/18 at 6:08 PM, Resident #7's behavior was described as Angry; Anxious, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger or anxiety. There was no documentation of interventions by staff. - On 9/18/18 at 6:11 PM, Resident #7's behavior was described as Angry; Anxious, she was able to express her feelings, needs, and thoughts, and understood others. There was no further description documented of how she displayed her anger or anxiety. There was no documentation of interventions by staff. - On 9/29/18 at 3:00 PM, Resident #7's behavior was described as Cooperative; Restless; Anxious. There was no further description documented of how she displayed her behaviors. There was no documentation of interventions by staff. - On 10/7/18 at 5:22 PM, Resident #7's behavior was described as Angry; Anxious, she was able to express her feelings, needs, and thoughts, and she understood others. There was no further description documented of how she displayed her anger or anxiety. There was no documentation of interventions by staff. - On 10/8/18 at 1:00 PM, Resident #7's behavior was described as Anxious; Restless. There was no further description documented of how she displayed her anxiety or restlessness. There was no documentation of interventions by staff. At 10:35 AM on 10/12/18, the DON stated when Resident #7 was admitted the physician changed her from [MEDICATION NAME] (an antipsychotic medication) to [MEDICATION NAME]. The DON stated a GDR was attempted but was unsuccessful. She stated when Resident #7 has behaviors staff will assess for pain or other causes. The DON stated the Behavior Monitoring flowsheet was completed once a shift. She confirmed the flowsheet did not include a further description for a specific mood and did not document interventions by staff. 6. Resident #9 was admitted to the facility on [DATE], with diagnoses which included [MEDICAL CONDITIONS], HTN, and Type II DM. Resident #9's physician orders, dated 10/1/18, included [MEDICATION NAME] 60 mg daily for neuropathic pain (a disease of the sensory system) and [MEDICATION NAME] 0.5 mg every 6 hours as needed for anxiety. There was no documentation in Resident #9's record she had diagnoses of [MEDICAL CONDITION] or anxiety. On 10/11/18 at 2:16 PM, the Pharmacy Director stated there was a Clinical Pharmacist who conducted monthly medication reviews. He stated he reviewed indications for medications with diagnoses and also looked for off-label indications. The Pharmacy Director stated if there was a discrepancy between indications for use and diagnoses he will review the record further. He confirmed Resident #9's record did not included diagnoses for [MEDICAL CONDITION], depression, or anxiety. On 10/11/18 at 4:24 PM, the DON was asked about Resident #9's order for [MEDICATION NAME] and what behaviors are staff monitoring for and she stated Resident #9 becomes tearful and repetitive if anxious. She confirmed there were no diagnoses of [MEDICAL CONDITION], depression or anxiety on Resident #9's list of diagnoses. 7. Resident #10 was admitted to the facility on [DATE], with diagnoses which included malaise, [MEDICAL CONDITION] (paralysis of one side of the body), HTN, and Type II DM. Resident #10's physician orders included [MEDICATION NAME] (an antidepressant/sedative medication) 100mg nightly starting 9/6/18 and [MEDICATION NAME] (an herbal sleep aid) 3 mg nightly for sleep trouble, starting 10/5/18. A consent for Psychoactive Medication, dated 09/16/18, documented the Trazadone was for sleep. Resident #10's care plan, dated 9/26/18, included interventions to increase his participation to maximize rehabilitation benefits, have consistent daily scheduling, and reduce the risk of escalation. The care plan included monitoring for side effects related to Resident #10's antidepressant medication including drowsiness, dry mouth, sedation, and agitation. The care plan included direction to report to the nurse and physician if the medication assisted with sleep and if any negative side effects were observed. On 10/12/18 at 9:35 AM, the DON stated We do not do a true monitor where staff note how many hours residents are awake/asleep. She stated the EMR documented whether sleep was adequate in the flow sheets, then the nurses write a note if the resident is up or having trouble sleeping. The DON stated the [MEDICATION NAME] was started during Resident #10's acute hospital stay. | 2020-09-01 |