| 26 |
BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION |
135007 |
98 POPLAR STREET |
BLACKFOOT |
ID |
83221 |
2019-03-01 |
756 |
D |
0 |
1 |
U2XH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, staff interview, and record review, it was determined the facility failed to ensure the pharmacy recognized and reported medication irregularities. This was true for 3 of 3 residents (#6, #10, and #22) whose monthly pharmacy medication reviews were reviewed. This failure created the potential for harm should residents receive medications that were unnecessary, ineffective, or used for excessive duration, or should residents experience adverse reactions from medications. The facility's policy for use of [MEDICAL CONDITION] drugs, dated 11/2018, documented the following: * PRN orders for [MEDICAL CONDITION] drugs shall be used only when the medication is necessary to treat a diagnosed specific condition documented in the record, and for a limited duration (i.e. 14 days.) 1. Resident #22 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #22's 90-day MDS assessment, dated 2/25/19, documented she was cognitively intact and received antianxiety medications daily. Resident #22's physician orders, dated 11/27/18, directed staff to provide [MEDICATION NAME] 0.5 mg 4 times daily as needed for anxiety. The Pharmacist Medication Reviews, completed on 11/30/18, 12/30/18, 1/31/19, and 2/26/19 did not have comments or recommendations made by the Pharmacist. On 2/28/19 at 3:54 PM, the Pharmacist stated if he did not make recommendations, the Monthly Pharmacist Chart Review form had a zero in the comment section. He stated he put his recommendations in the comment section. On 2/28/19 at 4:13 PM, the Pharmacist stated he was not paying attention to the PRN [MEDICAL CONDITION] medications when he conducted the resident's monthly medication review. He stated he should have been reviewing them. On 3/1/19 at 11:30 AM, the DON confirmed she had not received any recommendations from the Pharmacist for Resident #22. The Pharmacist review of Resident #22 did not include review of PRN medications and whether the orders were in place for more than 14 days. 2. Resident #10 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#10 with [MEDICATION NAME] light powder (a medication used to treat chronic diarrhea) 4 grams by mouth twice a day. On 2/11/19, additional physician direction was provided to staff to ensure the [MEDICATION NAME] was not administered within 2 hours of other medications. Resident #10's MAR from (MONTH) (YEAR) through Feburary 2019, documented Resident #10 received the [MEDICATION NAME] medication twice a day at 7 AM and 8 PM with other medications. The Monthly Pharmacist Chart Review documented the Pharmacist reviewed Resident #10's medications on 9/28/18, 10/30/18, 11/30/18, 12/30/18, 1/31/19, and 2/26/19 with no recommendations documented. On 2/28/19 at 6:25 PM, RN #2 stated the Pharmacist should have identified the [MEDICATION NAME] was given with other medications with his monthly reviews. The Pharmacist review of Resident #10 did not include review of PRN medications and whether the orders were in place for more than 14 days. On 3/1/19 at 8:40 AM, the Pharmacist stated the administration of [MEDICATION NAME] should be separated by a couple of hours from other medications. He stated the medication interacts with [MEDICATION NAME] and the [MEDICATION NAME] Resident #10 was receiving and should be separated by a couple of hours. On 3/1/19 at 11:27 AM, the DON stated she had not received recommendations from the Pharmacist regarding the administration of [MEDICATION NAME] and the administration of Resident #10's other medications. 3. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. On 2/28/19 at 9:47 AM, RN #2 stated the Trazadone was ordered PRN. She stated the order should have only been written for 14 days. She stated she was unable to tell if the Trazadone was repeated in an hour or not because the order was written together on the MAR and the MAR did not have a space for the nurse to document if the Trazadone was repeated in one hour. The Monthly Pharmacy Chart Review documented Resident # 6's medications were reviewed monthly from 6/30/18 through 2/26/19. Resident #6's Pharmacy Chart Review did not include documentation of recommendations from the Pharmacist. On 02/28/19 at 3:54 PM, the Pharmacist stated he should have caught the Trazadone may be repeated in an hour as needed. On 2/28/19 at 4:13 PM, the Pharmacist stated he was not paying attention to the PRN [MEDICAL CONDITION] medications when he conducted the monthly medication review. He stated he should have been reviewing them. On 3/1/19 at 11:23 AM, the DON confirmed she had not received recommendations from the Pharmacist for Resident #6. |
2020-09-01 |