cms_MT: 5300
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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5300 | RIVERSIDE HEALTH CARE CENTER | 275126 | 1301 E BROADWAY | MISSOULA | MT | 59802 | 2011-11-09 | 514 | D | 0 | 1 | WOER11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/7/11 at 12:30 p.m., a review of the active medical chart was completed. The physician ordered, "[MEDICATION NAME] 1 mg tablet take one or two tablets every 4 hours if needed for agitation" on 7/13/10". It was printed with the order on the MAR to chart the amount of [MEDICATION NAME] given. It was documented on the MARs: -March, 2011 dosage was not documented 20 of 23 times the [MEDICATION NAME] was given; -July, 2011 dosage was not documented 2 of 2 times the [MEDICATION NAME] was given; and -October, 2011 dosage was not documented 5 of 8 times the [MEDICATION NAME] was given. The MARs lacked consistent documentation of whether [MEDICATION NAME] 1 mg or 2 mg was administered to resident #3. The back of the MARs for 3/11, 7,11 and 10/11 lacked documentation of the dosage. The physician ordered, "[MEDICATION NAME] 1 mg take one tablet four times daily if needed for anxiety," on 7/13/10. It was documented on the MARs: -March, 2011 [MEDICATION NAME] PRN was administered 21 times; -April, 2011 [MEDICATION NAME] PRN was administered 11 times; -July, 2011 [MEDICATION NAME] PRN was administered 2 times; -August, 2011 [MEDICATION NAME] PRN was administered 2 times; and -September 2011 [MEDICATION NAME] PRN was administered 2 times. There was no documentation provided regarding the rationale for administering the as needed [MEDICATION NAME]. The physician ordered, "Ambien 5 mg take one tablet or two tablets at bed time," on 5/28/10. It was printed with the order on the MAR to chart the amount [MEDICATION NAME]. It was documented on the MARs for 8/2011, 9/2011, 10/2011 and 11/2011 [MEDICATION NAME] administered nightly. The MARs lacked documentation of whether one tablet or two tablets were administered. On 11/8/11 at 10:00 a.m., the DON stated that nursing staff were to document if one or two tablets were administered for [MEDICATION NAME] resident #3. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On admission resident #2 had an order for [REDACTED].). On the September 2011 MAR, three doses of [MEDICATION NAME] had been given on 9/7/11, 9/24/11, and 9/25/11. Of the three doses charted as administered, all lacked the amount given. On the October 2011 MAR, six doses of [MEDICATION NAME] had been given on 10/3/11 (2 doses), 10/6/11, 10/9/11, 10/13/11, and on 10/14/11. Of the six doses charted as administered, all lacked the amount given. On 10/14/11 the physician's orders [REDACTED]." On the October 2011 MAR, three doses of [MEDICATION NAME] had been given under the new order on 10/14/11, 10/15/11, and 10/16/11. Of the three doses charted as administered, all lacked the amount given. On the November 2011 MAR, two doses of [MEDICATION NAME] had been given on 11/2/11 and 11/3/11. Of the two doses charted as administered, both lacked the amount given. The nurses notes were reviewed and the amount of [MEDICATION NAME] given for the doses indicated could not be determined. Based on record review and staff interview, the facility failed to ensure medical records were complete and accurate for 2 (#s 2 and 3) of 15 residents reviewed. Findings include: | 2014-10-01 |