cms_NE: 6168

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
6168 NORTHFIELD RETIREMENT COMMUNITIES CARE CENTER 285271 2100 CIRCLE DRIVE SCOTTSBLUFF NE 69361 2016-06-06 333 J 1 0 VYV311 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number: 175 NAC ,[DATE].10D Based on record reviews and interviews, the facility failed to clarify dosage calculations prior to administering a narcotic medication to one sampled resident (Resident 5). The failure resulted in overdosing the resident resulting in the resident's death. Facility census was 47. Findings are: Record review of an undated Resident Admission Record for Resident 5 revealed the resident was admitted to the facility on [DATE]. Record review of a Palliative Care Consultation document for Resident 5 dated [DATE] revealed the resident was assessed by a Palliative Care Nurse Practitioner. The Nurse Practitioner described the resident as having steadily declined in the past 2 years since the resident fractured a hip. The resident was assessed sitting in a recliner and answered simple questions. The Nurse Practitioner recorded There are no signs of acute distress at this time. Following assessment of the resident the Nurse Practitioner ordered [MEDICATION NAME] liquid 1 mg (milligram) by mouth or sublingually (under the tongue) q (every) 12h (12 hours). Prescription sent to pharmacy. Record review of an untitled document revealed 30 cc (cubic centimeters or milliliters) of [MEDICATION NAME] was received at the facility on [DATE]. Record review of an Individual Resident's Controlled Substance Record for Resident 5 revealed 30 ml (milliliters) of [MEDICATION NAME] was received on [DATE]. Further review of the record revealed MA (Medication Aide)-J administered a 0.5 ml dose at 9:00 p.m. On [DATE], MA-F administered a 1 ml dose of [MEDICATION NAME] at 8:33 a.m. On [DATE], MA-I administered a 1 ml dose of [MEDICATION NAME] at 8:00 p.m. on [DATE]. Record review of Resident 5's Resident Progress Notes between [DATE] and [DATE] revealed no entry on ,[DATE] and an entry on [DATE] recorded at 8:41 p.m. which read: Entered room @ (at) 2030 (8:30 p.m.), resident has no noted pulse or resp (respirations) Record review of the facility's Medication Error Report forms for Resident 5 revealed the errors occurred on ,[DATE] and [DATE]. Description of the errors revealed the bottle from the pharmacy was correctly labeled c with 0.1 ml per 1 mg. Someone had blacked out the 0.1 ml (on the label). 0.5 ml (5 milligrams) was given on [DATE] @ 2100 (9:00 p.m.) by MA-J and 1 ml (10 mg) at 0830 (8:30 a.m.) by MA-F on [DATE]; and on [DATE] at 2000 (8 p.m.) by MA-I. The document recorded the Outcome to resident was Patient died at 2030 [DATE]. A separate Medication Error Report form for Resident 5 described the same incident and included a handwritten statement on [DATE] from LPN (Licensed Practical Nurse)-L which recorded I (LPN-L) marked out the label to prevent someone from giving wrong dose. MA-F asked me what dose to give as (the med aide) was confused from looking at the label. Phone interview with the Palliative Care Nurse Practitioner on [DATE] at 9:15 a.m. confirmed the Nurse Practitioner consulted for Resident 5 on [DATE] and wrote orders for [MEDICATION NAME] 1 mg to be administered every twelve hours. The Nurse Practitioner stated, that following the assessment of the resident on [DATE], the resident was not in any imminent danger from the disease process and the family and resident chose palliative care for comfort. When questioned in the Nurse Practitioner's opinion, what would affect a 5 mg dose and two subsequent 10 mg doses would have on Resident 5, the Nurse Practitioner stated due to frailty and [AGE] years of age, doses at that level would probably kill (the resident). Phone interview with the pharmacist dispensing the [MEDICATION NAME] for Resident was done on [DATE] at 9:45 a.m. The pharmacist stated having re-checked all orders and labels regarding Resident 5's [MEDICATION NAME] order. The pharmacist confirmed receiving an order from the Palliative Care Nurse Practitioner on [DATE] and verified the order called for [MEDICATION NAME] 1 mg every 12 hours. The Pharmacist verified the label sent out was on a typed label and identified to give 0.1 ml or 1 mg in the instructions. The bottle also identified the strength of the medication in the bottle was 10 mg per milliliter. When asked what a 10 mg dose of [MEDICATION NAME] would result in for Resident 2, the pharmacist replied that in a frail elderly person over [AGE] years of age and as potent as this ([MEDICATION NAME]) is that the first dose would cause some sedation but with progressive dosing accumulation would occur and likely result in death. The pharmacist stated that even a healthy young individual taking a 10 mg dose would experience severe sedation at a minimum. Interview with the facility DON (Director of Nursing) on [DATE] at 2:00 p.m. confirmed the facility staff had overdosed Resident 5 on [DATE] and [DATE]. The DON stated, from investigation, that the resident's [MEDICATION NAME] was received at the facility in a 30 ml bottle on [DATE]. The DON stated, that when logged into the computer, LPN-K had incorrectly typed in the order as 5 mg/ml rather than 10 mg/ml. When MA-J compared label to logged in order, MA-J was confused and asked for direction from LPN-K. LPN-K then directed MA-J to administer 0.5 ml (5 mg) which MA-J complied with and administered the medication at 9:00 a.m. LPN-K had not contacted the pharmacy or prescribing Nurse Practitioner for clarification of the orders. The DON stated that, on [DATE], MA-F also questioned the order and asked LPN-L for directions. LPN-L proceeded to tell MA-F the label was incorrect and crossed out the label instructing to administer 0.1 ml and changed the label to 1 ml without receiving any clarification from the pharmacy or the prescribing Nurse Practitioner. LPN-L instructed MA-F to administer 1 ml (10 mg) of the [MEDICATION NAME] with which MA-F complied at 8:33 a.m. At 8:00 p.m., MA-I administered 1 ml of [MEDICATION NAME] to Resident 5 based on the label change. The DON verified the resident was overdosed by 5 times the order on [DATE] and twice was administered 10 times the order on [DATE]. The DON verified the resident expired a half hour after receiving the third dose. Prior to the survey team exit on [DATE], the facility had terminated two employees regarding the incident. In addition, the facility's nurse consultants and DON arranged for immediate education for licensed nurses including dosing calculations for liquid medications, and review of a new policy for monitoring liquid medication dosages. Due to these measures, the Immediate Jeopardy was abated and scope and severity lowered to a G. 2019-06-01