cms_NE: 5
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5 | ST JANE DE CHANTAL | 285004 | 2200 SOUTH 52ND STREET | LINCOLN | NE | 68506 | 2017-01-03 | 329 | D | 0 | 1 | X2RI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.09D Based on record review and interview, the facility failed to provide non pharmacological interventions prior to the administration of an antianxiety medication and failed to evaluate the effectiveness of the medication after administration for one (Resident 265) of 41 residents sampled. The facility had a census of 109. Findings are: Review of Resident 265's MDS (The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility.) dated 12/11/16 revealed Resident 265 was cognitively intact with disorganized thinking, had indicators of depressed thoughts or feelings and no behaviors. Resident 265 required assistance to complete tasks of daily living, had occasional pain and had [DIAGNOSES REDACTED]. Review of Resident 265's Care Plan dated 12/20/16 revealed an identified problem of a potential for complications related to the use of antianxiety and antidepressant medication. Interventions included Compliment drug therapies, encourage participation in activities on the unit and therapies. Offer use of holistic cart with music and aroma therapies. Provide a quiet calm atmosphere when able. Review of Resident 265's Active Orders for (MONTH) (YEAR) revealed an order for [REDACTED]. Review of a Work List printed on 1/3/17 from the electronic medical record revealed Resident 265 was administered [MEDICATION NAME] .25 mg (milligrams) on 18 occasions during the month of (MONTH) (YEAR) at various times in the afternoon and evening. Further review of the electronic medical record revealed no documentation regarding what non pharmacological interventions were administered prior to administering the PRN antianxiety and no documentation of whether or not the [MEDICATION NAME] had been effective in treating the anxiety. Interview with Registered Nurse (RN) G on 12/27/16 at 2:30 PM revealed staff had a couple of places they could document both the effectiveness of the medication and the non-pharmacological interventions attempted prior to administration including the Adult Assessment and Interventions. RN G then confirmed that, after reviewing the medical record, RN G was unable to find where any staff had evaluated the effectiveness of the antianxiety after administration. RN G was also unable to find consistent documentation that non pharmacological interventions had been attempted prior to the administration of the [MEDICATION NAME]. Review of the Adult Assessment & Interventions in (MONTH) (YEAR) for Resident 265 revealed Resident 265 was assessed to be anxious, agitated, angry, yelling, crying, restless, and screaming at times. The Assistive Device provided for these symptoms was Antianxiety medication. A non-pharmacological intervention was implemented two times out of the 18 occasions and was documented to be frequent verbal cues/redirection to get along with others and frequent checks. Interview with the Director of Nursing (DON) on 01/03/2017 at 4:22 PM revealed staff should be offering non pharmacological interventions prior to administration and evaluating the effectiveness of thee antianxiety medication once given. | 2020-09-01 |