| 3020 |
OMAHA NURSING AND REHABILITATION CENTER |
285240 |
4835 SOUTH 49TH STREET |
OMAHA |
NE |
68117 |
2019-11-26 |
755 |
J |
1 |
0 |
K9BO11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > State Licensure tag 175 NAC ,[DATE].10. Based on interview, observation and record review; the facility failed to administer medications for Residents 1 and 2 using the 5 Rights of medications administration. This affected 2 of 2 sampled residents. The facility identified a census of 63 at the time of the survey. Findings are: The 5 Rights of medication administration are The Right Medication The Right Dose The Right Time The Right Route The Right Patient The five rights, as stated, focus on the performance of individuals and do not reflect the fact that drug safety is a culmination of efforts of professionals from several disciplines, the responsibility for accurate drug administration lies with multiple individuals and reliable systems. Some of the factors contributing to a medical team's failure to accurately verify the five rights, despite their best efforts, include: Poor Lighting [NAME] An interview with the DON (Director of Nurses) at [DATE] at 10:48 AM revealed; that the staff had done a sweep of the property and found a bottle of Smirnoff Vodka 375ml. This was found in the front of Entrance of the building in a trash can. In the interview with the DON confirmed; that the medication administration for Resident 1 and Resident 2 was done outside the building. The DON reported that they did not know how well lit the area was at the time of medication administration. The DON confirmed that both Resident 1 and Resident 2's medication were delivered at the same time, outside. An interview on [DATE] at 10:48AM with RN (Registered Nurse) at UNMC (University of Nebraska Medical Center) revealed; Resident 1 was positive for opioid and alcohol. Resident 1's BAC (Blood Alcohol Concentration) was 239. The specific opioid and [MEDICATION NAME]. Record review of Resident 1's MAR (Medication Administration Record) revealed; No record of [MEDICATION NAME]. Record review of Resident 1's Quarterly MDS (Material Data Set- a comprehensive federally mandated process for clinical assessment to determine the functional and health care needs of residents) dated [DATE] revealed; Section C BIMS (Brief Interview for Mental Status-is a calculator that checks the residents cognitive impairment and whether further intervention is required for dementia diagnosis.) Score of 13, a score of 13 shows intact cognition. Section D Total Severity Score was 03 with Section [NAME] Little interest or pleasure in doing things ,[DATE] days section G trouble concentrating on things such as reading the newspaper or watching television ,[DATE] days. Section [NAME] Behaviors: indicates no behaviors. Section G Functional Status: indicates toilet use one assist, set up. Requires supervision for bed mobility, walking in corridor, locomotion off the unit, eating and toilet use. Section G 0300 Balance during transitions and walking-was steady at all times. Section I Diagnosis: [REDACTED]. Section J Health conditions- No pain, has had a fall with no injury, Section K: Nutrition: 5'1 and weight was 156 Section M: medications: [REDACTED]. Record review of Resident 1's Lab reports from UNMC dated [DATE] revealed; the toxicity screen for Resident 1 showed that the positive results for: Opiates and [MEDICATION NAME]. Record review of Initial Visit Critical Care Medicine dated [DATE] at 1:18Am revealed Resident 1 had a history of [REDACTED]. Resides at Nursing Home and was found unresponsive and purple. CPR was performed for 3 minutes. There was a pulse when paramedics arrived and was given [MEDICATION NAME] without effect. Resident 1 reported nonsmoking and had quit 8 months ago. Resident 1 reported no drug use. Physical exam revealed: Alert, appears stated age, cooperative, no distress and sedated and on a ventilator. Record review of UNMC Assessment and Plan dated [DATE] revealed; the principle problem was [MEDICAL CONDITION], elevated lactic acid level, acute [MEDICAL CONDITIONS], altered mental status, Insulin dependent diabetes mellitus. Record review of Attending Neurology dated [DATE] revealed; Resident 1 had a history of [REDACTED]. Resident 1 required resuscitation and CPR. Resident 1 was found to have an alcohol level over 200. Resident 1 continued to be intubated, alert and cooperative. Resident 1's parent was concerned about further [MEDICAL CONDITION]. Record review of Resident 1's Medication Admin Audit Report dated [DATE] the medications were documented at 23:53PM (11:53PM) [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) Tablet 500mg BID, [MEDICATION NAME] (benzodiazepines used to treat anxiety disorders) Tablet 0.5mg at HS, [MEDICATION NAME] (used to treat certain mental/mood conditions (such as [MEDICAL CONDITIONS] disorder, episodes [MEDICAL CONDITION] depression)Tablet 25mg at HS, [MEDICATION NAME] (a natural hormone associated with sleep onset) Tablet 3 mg 1 tablet at HS for sleep, Jolessa (a combination hormone medication used to prevent pregnancy) Tablet 0.15mg-0.03mg 1 tablet at HS, and [MEDICATION NAME] (medicine that helps lower LDL cholesterol) Tablet mg at HS. (RESIDENT WAS ALREADY OUT TO THE HOSPITAL AT THE TIME THE MEDICATIONS WERE GIVEN) [MEDICATION NAME] (a man-made rapid acting insulin for adults with diabetes) Flex Pen Sliding scale documented at 00:14AM (12:14AM) [MEDICATION NAME] Flex Pen Inject 5 units SUBQ. B. An interview with Resident 2, on [DATE] at 4:30PM revealed, that (gender) felt like the facility was blaming them for Resident 1's incident. Resident 2 reported if they would have known Resident 1 was drinking they would have got the nurse. Resident 1 had laid on Resident 2's bed, head on the pillow. Resident 2 reported Resident 1 started to snore. Resident 1 had told Resident 2 they did not snore so Resident 2 thought it was cute. Resident 2 reported that about 2 minutes later Resident 2 observed that Resident 1 was no longer snoring and assisted Resident 1 onto back. Resident 2 reported Opened Resident 1's eye lid was dilated, Lips turned blue did a sternal rub. Resident 1 did not respond, so Resident 2 went to the nurse told the nurse that it was a code, Resident 2 reported the nurse started chest compressions and within a minute they got Resident 1 back. Resident 2, who was visibly upset and reported that Resident 1 spoke about drinking all the time. Resident 2 encouraged Resident 1 not to drink and reported that the parents would not have put Resident 1 here if it was not necessary. Resident 2 reported had started smoking since the stress- 5 people have died at the facility since admission and had starting smoking related to that. Resident 2 reported that (gender) told the nurses Resident 2 thought (gender) did not get their own medications. There were not enough medications in the cup. Resident 2 reported the nurse questioned whether or not the residents were given each resident the right medications. Resident 2 requested for the nurse to check the medication administration sheets and the nurse refused telling Resident 2 that the right medications had been given. Resident 2 reported that in the cup of medications were only 3 small round pills, and there should have been more pills. Resident 2 reported that Resident 1 had already swallowed the medications. Resident 2 felt if brought to the attention of the nurses the medications were mixed that Resident 1 could have been given [MEDICATION NAME] to reverse the effects. Resident 2 reported that (gender) approached the nurse about the mix up of medication and the nurse would not check to see if the medication was given. Resident 2 reported that (gender) had some medical training. Resident 2 reported that Resident 1 called 8:13 and next time at 9pm and they followed Resident 1 outside and had a smoke. No words were slurred. Reported that the medication were given was 20 minutes with the time lapse Resident 2. Resident 2 reported that for some the Administrator wanted someone to observe Resident 2 is outside, sign out write the time. It is something they do if they sign out supposed to sign out and Resident 1 never does. Resident 2 pointed out the area both residents were sitting in and reported that area was not well lit and Nurse A delivered both residents medications at the same time. C Record Review of Administrator notes interview with Nurse A: Nurse A indicated that Resident 1 and Resident 2 were seen to be exiting the facility shortly before 8PM on [DATE]. Nurse A reported that Resident 2 told the nurse that (gender) would get medication is a little while. Resident 1 and 2 were noted to be in the garden area. Nurse A reported when it was time for medication administration, Nurse A prepared Resident 1 and 2 medications and took them outside and delivered the medications to each of them. Nurse A reported picking up cups that were outside with Resident 1 and 2. Nurse A reported that there was an energy drink present and described it as looking like red bull. Nurse A reported smelling something strange and in hindsight thinks this could have been alcohol, but at the time assumed it was water. Nurse A reported it was roughly 10 pm when Resident 1 and 2 came inside and stopped at the nurse's desk on the way to Resident 2's room. Nurse A reported after 10pm nurse arrived, Resident 2 came out of their room and reported Resident 1 was not breathing. Nurse A rushed to the room, confirmed no pulse/respirations and called for nurses from other floor to come down. Nurse B came in and placed the board under Resident 1 and began compressions. Nurse C called 911 and entered the room and began compressions to Resident 1. Nurse A reported prepared oxygen and suction machine for use if needed. Shortly after compression and respirations Nurse B and C were able to restore a pulse and breathing. Shortly after EMT arrived and took over. An interview with Nurse B on [DATE] revealed; Nurse B reported that they were finishing documentation and giving report to the night shift nurse when heard the page for stat response to 1st floor. Nurse B reported they used the stairs and rushed to 1st floor and was directed to go to Resident 2's room where she encountered Nurse A preparing to respond to code. Nurse B reported that Resident 1 had no pulse of respirations. Nurse B placed that code board under Resident 1 and coordinated with Nurse C to support rescue breathing while Nurse B did compressions. Nurse B reported that Resident 1's respirations and pulse were restored. |
2020-09-01 |