| 51 |
BELLA TERRA OF BILLINGS |
275020 |
1807 24TH ST W |
BILLINGS |
MT |
59102 |
2018-06-14 |
759 |
E |
1 |
1 |
JJY911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% in which three medications were omitted from the medication administration for 1 (#227), and failed to administer a medication in the dose and type prescribed, for 1 (#43), of 31 sampled and supplemental residents. The facility's medication error rate was 7%. Findings include: 1. During an observation on 6/12/18 at 7:40 a.m., staff member L prepared and administered the following medications for resident #227: - [MEDICATION NAME] 5 mg, one tablet, - Carvedilol 3.125 mg, one tablet, - [MEDICATION NAME] 20 mg, one tablet, - acidophilus, one tablet, - [MEDICATION NAME] Inhaler 250/50 mcg, one puff, - aspirin 81 mg, one tablet, - calcium 500 mg with Vitamin D, one tablet, - [MEDICATION NAME] and [MEDICATION NAME], two capsules, - magnesium 64 mg, one tablet, - Senna Plus, one tablet, - Thera-M, one tablet, - [MEDICATION NAME] 80 mg, one tablet, - cranberry 465 mg, one tablet. Review of resident #227's EMAR for (MONTH) (YEAR), and the Physician order [REDACTED]. - one losartan 50 mg tablet for hypertension, - one [MEDICATION NAME] 25 mg tablet for [MEDICAL CONDITION], and - one [MEDICATION NAME] 5 mg tablet for history of urinary [MEDICATION NAME]. During an interview on 6/13/18 at 11:34 a.m., staff member L stated she was not aware she had omitted the three medications from her medication pass for resident #227. She stated she reviewed the medications on the EMAR and then retrieved the medication card. She would then pop the medication out of the card, and return the card to the drawer. She stated the EMAR could be confusing, because there were medications which were ordered at different times so the EMAR would not turn yellow even if the medication was due at the same time as the other medication. She stated the medications were entered into the EMAR by the nurse manager, and sometimes different nurse managers order the medications differently. The staff member stated she felt there was not always consistency with the way the medications were entered into the EMAR. She stated the only time she would intentionally omit medications from a resident's medication regimen, would be if there was a physician order, or the resident was outside of a safe parameter for administration; for example, if a pulse was too low, or a blood pressure was too low. During an interview on 6/13/18 at 11:45 a.m., staff member C stated it was the expectation of staff to use the rights of medication administration, follow any new physician orders, and administer medications as outlined in the EMAR for every resident. A review of the facility's policy and procedure, titled Medication Pass, showed, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures . 2. During an observation of medication administration on 6/12/18 at 7:50 a.m., staff member AA administered resident #43 one calcium antacid chewable tablet of 500 mg orally. A review of resident #43's Order Review Report, showed the resident was ordered to receive calcium [MEDICATION NAME] 600 mg tablet, one tablet PO one time per day. During an interview on 6/13/18 at 8:45 a.m. staff member U was shown resident #43's physician's orders [REDACTED].#43's corresponding medication bottle from the facility's medication cart. She provided the same stock bottle of calcium antacid tablets, 500 mg per tab, that had been used to administer resident #43's calcium [MEDICATION NAME] on the morning of 6/12/18. Staff member U was shown resident #43's physician's orders [REDACTED]. She said the nurses giving medications should have clarified the order with the facility pharmacist and if what the physician had ordered was not available, the physician should have been called to order what equivalent medication was available. |
2020-09-01 |