| 41 |
BELLA TERRA OF BILLINGS |
275020 |
1807 24TH ST W |
BILLINGS |
MT |
59102 |
2018-06-14 |
554 |
D |
0 |
1 |
JJY911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents, who had medications in their room, stored them safely, and had physician orders [REDACTED].#s 3 and 61) of 19 sampled residents; and failed to assess 1 (#3) of 19 sampled residents for self-administration of medications. Findings include: 1. During an interview on 6/12/18 at 3:06 p.m., resident #3 stated she had been sick, with a bad cold, during the winter. She stated she was doing okay, as she had medications like cough drops, and a rub, that she could take by herself. She did not know where the medication was at the time, as she had moved from one room to another. Review of resident #3's Annual MDS, with an ARD of 12/12/17, showed the resident had a score of 14, very little to no cognition problems. Review of resident #3's Order Review Report, dated 4/1/18 - 4/30/18, showed the resident only had a medicated chest rub ointment, as needed for congestion, may have at bedside. The order date was 2/25/18. During an interview on 6/13/18 at 2:18 p.m., staff member B stated resident #3 did have a physician order [REDACTED].#3 to self-administer any medications. The staff member was unable to find the medications in resident #3's room. The staff member said the nursing staff were getting a discontinuation order of the medication. Review of resident #3's Care Plan, with a revision date of 5/31/18, did not show the resident was able to self-medicate any medication. Review of a Nurse/Provider Communication Form, dated 6/13/18, showed nursing staff had requested an order to discontinue the at the bedside order for resident #3's [MEDICATION NAME] cream, as the resident had not been using it for the past 30 days. There was no document showing the facility had put in a request to discontinue the chest rub or that the nursing staff were aware that resident #3 had cough drops. 2. During an observation and interview on 6/11/18 at 4:48 p.m., an opened bottle of Tums antacids, an opened container of [MEDICATION NAME] topical powder, and a squeeze bottle of Equate nasal spray were on a shelf, above resident #61's bedside stand. During the interview, resident #61 stated he had a physician's orders [REDACTED]. Review of resident #61's Annual MDS, with an ARD of 7/4/17, showed the resident was capable of making reasonable decisions. Review of resident #61's Physicians' Recapitulation orders, dated 4/1/18 - 4/30/18, showed resident #61 had orders for: - Calcium antacid tablet chewable 500 mg, give one tablet by mouth every two hours as needed for heartburn, 15 times maximum, may keep at bedside, - Ayr saline nasal no drip gel, 1 unit in each nostril every eight hours as needed for dry nares. The order did not include self-administration of the medication and, - [MEDICATION NAME] 100,000 U/G powder, apply to affected area topically three times a day for rash. The order did not include self-administration of the medication. During an interview on 6/14/18, at 9:07 a.m., staff member J stated resident #61 was administering nasal spray and antacids by himself. The staff member stated resident #61 did not have an order to self-administer the nasal spray or powder. Review of resident #61's Self-Administration of Medication Evaluation, showed he had been assessed to have Tums, one by mouth as needed on 8/10/17. The evaluation did not include the [MEDICATION NAME] powder, or the nasal spray. The form showed the self-administration of the medication would be on the care plan. Review of resident #61's Care Plan, with a review completion date of 6/8/18, did not show that resident #61 was able to safely self-administer the Tums, the [MEDICATION NAME] powder, or the nasal spray. The care plan did not include a plan to address safety for other residents, related to the medications not being secured in a locked place, but in resident #61's room, on a shelf, viewable from the doorway. Review of a revision of resident #61's Care Plan, dated 6/13/18, showed an addition that the resident's ability to have only Tums by his bedside, and a self-administration review would be completed every three months, in conjunction with the MDS calendar. The care plan did not include the self-administration of the [MEDICATION NAME] or the nasal spray. |
2020-09-01 |