| 65 |
WEISER CARE OF CASCADIA |
135010 |
331 EAST PARK STREET |
WEISER |
ID |
83672 |
2016-10-21 |
332 |
E |
0 |
1 |
224112 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, it was determined the facility failed to ensure a medication error rate less than 5 percent. This was true for 5 of 33 medications (15%) during medication pass observations which affected 4 of 12 sampled residents (#14, #16, #20 and #21). The failure created the potential for [DIAGNOSES REDACTED] when rapid acting insulin was administered too early before a meal and for oral [MEDICAL CONDITION](thrush) to develop from lack of rinsing and spiting after inhalation of a corticosteroid medication. Findings include: The manufacturer's documented [MEDICATION NAME] (Insulin [MEDICATION NAME]) as a rapid acting insulin and that an injection of [MEDICATION NAME] should immediately be followed by a meal within 5-10 minutes. On 12/14/16 at 11:10 am, the Administrator provided the facility's Insulin Quick Reference, dated 2002, which documented [MEDICATION NAME] insulin, Should be given just prior to .eating. The Nursing (YEAR) Drug Handbook patient teaching regarding [MEDICATION NAME]documented, .give insulin at appropriate time around a meal . 1. Resident #14 was readmitted to the facility in (MONTH) (YEAR) with multiple diagnoses, including DMII, asthma and [MEDICAL CONDITION]. Resident #14's Active Orders As Of: 12/14/16 included a 4/6/16 order for [MEDICATION NAME]per sliding scale SQ before meals and at bedtime and a 7/24/16 order for [MEDICATION NAME] suspension inhaled twice a day. a. On 12/13/16 at 11:10 am, LN #3 was observed as she administered Resident #14's rapid acting [MEDICATION NAME] insulin. At 11:15 am, the LN said lunch was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. Resident #14's rapid acting insulin was administered 50 minutes before the meal. b. On 12/14/16 at 8:55 am, LN #1 was observed as administered an inhaler medication, 6 oral medications then [MEDICATION NAME] (corticosteroid) inhalation suspension via nebulizer to Resident #14. After the [MEDICATION NAME] nebulizer treatment, LN #1 did not encourage or instruct Resident #14 to rinse his mouth and spit or provide water for him to do so. On 12/14/16 at 9:25 am, LN #1 said she did not have Resident #14 rinse his mouth and spit after the [MEDICATION NAME] nebulizer treatment but she would go and do it right then. 2. Resident #16 was admitted to the facility in 2013, with multiple [DIAGNOSES REDACTED]. Resident #16's Active Orders As Of: 12/14/16 included orders for [MEDICATION NAME]per sliding scale SQ with meals every day, ordered 8/3/16. On 12/13/16 at 11:15 am, LN #3 said the lunch meal was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. On 12/13/16 at 11:30 am, Resident #16 told LN #3 that he may not eat lunch. LN #3 told Resident #16 his sliding scale called for 4 units of [MEDICATION NAME]. Resident #16 said he would take 2 units of insulin but not 4 units. Resident #16 also refused 2 oral medications and said he was not going to eat at lunch time. On 12/13/16 at 11:35 pm, the LN was observed as she administered [MEDICATION NAME] 2 units SQ into Resident #16's left abdomen. Resident #16's rapid acting insulin was administered 25 minutes before the lunch meal which he said he was not going to eat and the dose was decreased without a physician's orders [REDACTED].>3. Resident #21 was readmitted to the facility in (MONTH) (YEAR) with multiple diagnoses, including DMII. Resident #21's Active Orders As Of: 12/14/16 included [MEDICATION NAME]per sliding scale SQ before meals, dated 11/22/16. On 12/13/16 at 11:15 am, LN #3 said the lunch meal was scheduled for 12:00 pm and that she usually waits to give sliding scale insulin 30 minutes or less before meals. On 12/13/16 at 11:20 am, LN #3 was observed as she administered Resident #21's rapid acting [MEDICATION NAME] insulin. Resident #21's rapid acting insulin was administered 40 minutes before the meal. On 12/14/16 at 2:40 pm, the DNS said [MEDICATION NAME]should be administered 15 minutes or less before a meal. On 12/14/16 at 4:15 pm, the DNS said the facility references the Nursing (YEAR) Drug Handbook and their pharmacy regarding medications. 4. Resident #20 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #20's (MONTH) (YEAR) physician orders [REDACTED]. The [MEDICATION NAME] dose was to be held if Resident #20 was unable to eat the corresponding meal. The sliding scale was as follows: 0 - 69 = 0 units, refer to hypoglycemic policy 70 - 80 = 0 units 81 - 100 = 3 units 101 - 150 = 12 units 151 - 200 =19 units 201 - 250 = 28 units 251 - 300 = 33 units 301 - 350 = 36 units 351 - 400 = 40 units 401+ - 35 units and notify MD if greater than sliding scale range. On 12/14/16 the following observations were made: *11:10 am, LN #1 checked Resident #20's blood sugar. It was 234. *11:17 am, LN #1 administered 28 units of [MEDICATION NAME]to Resident #20. *12:05 pm, Resident #20 was at a dining room table waiting for his meal to be served. *12:10 pm, the food trays were being delivered to residents in the dining room. *12:20 pm, Resident #20 was being assisted to eat. On 12/14/16 at 2:16 pm, the DNS said, she believed [MEDICATION NAME] should be given 15 minutes before meals. |
2020-09-01 |