cms_NE: 10214

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
10214 KEARNEY COUNTY HEALTH SERVICES 2.8e+298 727 EAST 1ST STREET MINDEN NE 68959 2012-08-01 333 J 0 1 NRZX11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE 175 NAC 12-006.10D Based on record review and staff interview, revealed the facility staff failed to administer medication to Resident 19 without a significant medication error. The facility census was 30 at the time of the survey and the survey sample size was 26. Findings are: Review of the DISCHARGE AND DISCHARGE SUMMARY SHEET revealed the resident was admitted on [DATE] and readmitted [DATE] with diagnoses of spinal stenosis, history of sacral fracture, hypertension, constipation, [MEDICAL CONDITION] one eye right, weakness, depression, cataract, dementia. Review of Resident 19's MDS (a federally mandated comprehensive assessment tool used for care planning) dated 4/12/2012 revealed the BIMS score was 5 of 15. The resident experienced short and long term issues. The MDS addressed no behaviors. Continued review revealed limited assist of one person physical assist for bed mobility, locomotion on unit and personal hygiene. The MDS revealed the resident required an extensive assist of one person physical assist for transfers, walk in the room, walk in the hall and dressing. The MDS revealed the resident was dependent on two staff physical assist for toilet use. Further review of the MDS revealed the medication review was coded the resident received an antianxiety on day in the assessment period and an antidepressant every day for the 7 days during the assessment period. Review of the Initial Review and Investigation dated 7/3/2012 found an entry that Resident 19 was admitted to the hospital. No definite pneumonia was noted. Resident 19 was treated with [MEDICATION NAME] (antidote may displace opiod [MEDICATION NAME] from their receptors)--for possible narcotic overdose. Review of the admitting note dated 7/3/2012 revealed the primary [DIAGNOSES REDACTED]. Was treated with [MEDICATION NAME] times 2. Review of the Physician Telephone Order dated 7/1/2012 found an order of ABH ([MEDICATION NAME]) gel 1 ml (milliliter) topical TID (three times a day) PRN (as needed) apply to hairless area. Further review of the Physician Telephone Order revealed no [DIAGNOSES REDACTED]. Review of the MAR (Medication Administration Record) dated 7/1/2012 showed an entry ABH gel 1 ml ([MEDICATION NAME] .5 mg, [MEDICATION NAME] 12.5 mg, [MEDICATION NAME] .5 mg) topical PRN TID for agitation/restlessness. Apply topically to hairless area. Review of the Pharmacy Communication Sheet--Long Term Care revealed ABH gel was not ordered for Resident 19. Review of the label on the ABH gel that was borrowed from Resident 28 and administered to Resident 19 reads ABH 1:25:1 mg/ml. This was twice the dosage written on the MAR. The Medical Chart did not reveal a dosage for the ABH gel that was administered to Resident 19. Interview with the DON on 7/25/2012 at 11:02 AM confirmed the physician order [REDACTED]. The DON stated the facility staff failed to clarify a dosage for the mixture. Interview with the DON on 7/25/2012 at 11:02 AM stated the staff borrowed medication from Resident 28 to administer to Resident 19. The DON confirmed the medication borrowed was ABH gel. Interview with LPN-T (Licensed Practical Nurse) on 7/25/2012 at 1:39 PM stated I wrote the dosage on the MAR indicated [REDACTED]. When asked if Resident 19 was on Hospice on 7/1/2012 LPN-T stated I don't remember. Interview on 7/25/2012 at 2:11 PM with LPN-R (Licensed Practical Nurse) stated the ABH gel was borrowed from Resident 28 to administer to Resident 19. Stated 1 ml was administered as was indicated on the MAR. Interview with the Pharmacist on 7/26/2012 at 9:06 AM revealed the Pharmacy formulary addressed the mixture of the ABH gel. The ABH gel mixture was [MEDICATION NAME] 1 mg/ml (milligram per milliliter), [MEDICATION NAME] 25 mg/ml and the [MEDICATION NAME] 1 mg/ml that was sent to the facility. The Pharmacist stated when there was a question on the dosage the nurse gave them the dose of the medication. Interview with the PA (Physician Assistant) on 7/26/2012 at 12:22 PM stated direction was given to the LPN to borrow ABH gel from a resident and administer it to Resident 19 did not feel one dose would hurt anything. The PA stated thought the ABH gel only came in one dose. Interview with the DON on 7/30/2012 at 9:10 AM revealed the facility had no policy on Medication Administration. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1) Inservice training with all staff, licensed or certified, to administer medication related to the Five Rights of Medications and medication error reporting and documentation; 2) All resident medications were checked against current physician orders [REDACTED]. 3. Implementation of new policies MEDICATION ERROR GUIDELINES, TAKING OFF ORDERS, and CHECKING MEDICATION IN FROM PHARMACY. The immediacy has been removed, however, the deficient practice has not been totally corrected. Therefore, the scope and severity has been lowered to D. 2016-02-01