cms_ID: 20
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
20 | ST LUKE'S ELMORE LONG TERM CARE | 135006 | 895 NORTH 6TH EAST | MOUNTAIN HOME | ID | 83647 | 2018-10-12 | 759 | D | 0 | 1 | SC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure a medication error rate less than 5 percent. This was true for 2 of 33 medications (6.06%) administered during medication pass and effected 2 of 5 residents (#65 and #114) observed during medication pass. This failed practice placed residents at risk of not receiving medications as ordered by the physician and had the potential to lessen the effectiveness of the medications administered. Findings include: 1. Resident #114 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #114's physician orders, dated 9/27/18, included [MEDICATION NAME] (an acid reflux medication) 40 mg by mouth every morning before breakfast (served at 7:45 AM - 8:45 AM). On 10/12/18 at 8:45 AM, RN #1 was observed as she administered morning medications to Resident #114, which included the medication [MEDICATION NAME]. Resident #114 had finished her breakfast and was sitting in the activity room. 2. Resident #65 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #65's physician's orders [REDACTED]. On 10/12/18 at 9:11 AM, RN #1 was observed as she administered morning medications to Resident #65, which included [MEDICATION NAME]. Resident #65 had finished her breakfast and was sitting in her wheelchair in her room. On 10/12/18 at 9:30 AM, RN #1 stated she did not know why the [MEDICATION NAME] for Resident #114 and Resident #65 were scheduled for 8:00 AM. RN #1 stated [MEDICATION NAME] was usually scheduled for 7:00 AM. On 10/12/18 at 2:35 PM, the DON stated sometimes the medication delivery times in the EMR changed. The DON stated the [MEDICATION NAME] should be given during the 7:00 AM medication pass. | 2020-09-01 |