cms_ID: 49
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 |
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49 | WEISER CARE OF CASCADIA | 135010 | 331 EAST PARK STREET | WEISER | ID | 83672 | 2018-06-15 | 759 | D | 0 | 1 | GRQ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 25 medications (8%) which affected 1 of 7 residents (#2) whose medication passes were observed. This failure created the potential for harm when Resident #2 received doses in excess of physician orders [REDACTED]. Findings include: The facility's undated policy and procedure for nasal inhalers, sprays, and aerosols, documented the following: * Verify the physician's orders [REDACTED]. * Occlude one of the resident's nostrils, insert the tip into the open nostril and squeeze quickly and firmly one time. * Have the resident hold their breath for a few seconds then exhale through the mouth. * Repeat the ordered number of times in each nostril. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] reflux disease and acute sinusitis. Resident #2's physician orders, active as of 6/14/18, documented the following: * [MEDICATION NAME] Proprionate Suspension (a nasal steroid spray) 50 mcg 2 sprays each nostril twice a day for chronic rhinosinusitis. * [MEDICATION NAME] Suspension 200-200-20 mg/5 ml give 2 tsp every 6 hours as needed for stomach upset. Resident #2's (MONTH) (YEAR) MAR indicated [REDACTED] * The [MEDICATION NAME] nasal spray was administered each day from 6/1/18-6/14/18. * The [MEDICATION NAME] was administered on 6/8/18, 6/10/18, 6/12/18, and 6/14/18. On 6/14/18 at 9:19 AM, RN #1 administered medications to Resident #2. RN #1 administered two sprays of [MEDICATION NAME] nasal spray to Resident #2's right nostril and left nostril. RN #1 then administered three additional sprays of [MEDICATION NAME] to Resident #2's right nostril and two additional sprays to the left nostril. When asked how many sprays should be administered, RN #1 said it was two sprays in each nostril. When the surveyor pointed out to RN #1 that she administered 5 sprays in right nostril and 4 sprays in the left nostril, RN #1 said Oh. On 6/14/18 at 12:05 PM, RN #1 said sometimes Resident #2 appeared like he didn't sniff up all the nasal spray so she gave more sprays. RN #1 said she normally would not give that many sprays. On 6/14/18 at 9:20 AM, RN #1 administered Advanced Antacid (a generic form of [MEDICATION NAME]) 30 mls to Resident #2. On 6/14/18 at 2:50 PM, RN #1 said the order for [MEDICATION NAME] was 2 tsp, which equaled 10 mls. RN #1 said she administered 30 mls of [MEDICATION NAME] to Resident #2 and was thinking it was tablespoons. | 2020-09-01 |