| 9242 |
GOLDEN LIVINGCENTER - GRAND ISLAND PARK PLACE |
285105 |
610 NORTH DARR AVENUE |
GRAND ISLAND |
NE |
68803 |
2013-03-21 |
333 |
J |
0 |
1 |
FG2G11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10D Based on record review and interview, the facility failed to ensure 3 residents (Resident 09, 64, and 57) were free of significant medication errors. These failures involved the administration of narcotic and anticoagulant medications. The facility census was 55 and the survey size was 45. Findings are: A. Review of the facility's MEDICATION ERROR AND ADVERSE DRUG REACTION REPORTING dated 10/07 revealed Medication Error/Variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm; and Medication errors and adverse drug reactions are considered significant if they: a. Require discontinuing a medication or modifying the dose b. Require hospitalization c. Result in disability d. Require treatment with a prescription mediation e. Result in cognitive deterioration or impairment f. Are life threatening g. Result in death. B. Review of an ADMISSION RECORD dated 7/12/12 revealed Resident 09 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].), Cramp of limb, Chronic pai[DIAGNOSES REDACTED], and [MEDICAL CONDITIONS]. Review of Resident 09's medical record revealed the resident had been transported to the hospital emergency roiagnom on [DATE] for Decrease Level of Consciousness and on 3/7/13 for Narcotic overdose - accidental. Review of Resident 09's physician's orders [REDACTED].>- 2/20/13: [MEDICATION NAME] 50 mcg (micrograms)/hr (hour) [MEDICATION NAME] Patch at bedtime. Change every 3 days; - 3/6/13: may resume [MEDICATION NAME] 25 mcg to skin tonight; - 3/8/13: D/C (discontinue) [MEDICATION NAME] Patch. Review of the 2012 Nursing Drug Handbook revealed the [MEDICATION NAME] Patch was an opioid or narcotic medication used to treat moderate to severe chronic pain. Black box warnings revealed the [MEDICATION NAME] should be used with caution in patients with [MEDICAL CONDITION], decreased respiratory reserve, potentially compromised respiration, or [MEDICAL CONDITION] and in elderly or debilitated patients. The Nursing Drug Handbook revealed usage of the [MEDICATION NAME] could cause respiratory depression or an altered level of consciousness. Review of Resident 09's Medication Administration Record [REDACTED]. Review of Resident 09's CONTROLLED DRUG RECORD revealed 1 [MEDICATION NAME] 50 mcg/hr patch had been removed from the narcotic count on 3/10/13 at 8:00 PM. During an interview on 3/13/13 at 8:52 AM, Nursing Assistant (NA) - I revealed Resident 09 had a [MEDICATION NAME] on the right shoulder on 3/12/13 at about 2:00 PM when NA-I assisted Resident 09 with bathing. Review of Resident 09's Progress Notes revealed on 3/12/13 at 8:17 PM: located fentynal patch 50 mcg on resident R (right) Back dcd (discontinued) patch at this time. C. Review of an ADMISSION RECORD dated 2/13/13 revealed Resident 64 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a communication dated 11/27/12 with Resident 64's physician revealed admitted (with) 4 daily orders for [MEDICATION NAME]. patient states [MEDICATION NAME] is QID (4 times daily) alternating, could you please clarify 15 and 20 mg (milligrams) - 0500 (5:00 AM) 15 mg, 1100 (11:00 AM) 20 mg, 1700 (5:00 PM) 15 mg, 2300 (11:00 PM) 20 mg. The physician responded This is correct. Review of the 2012 Nursing Drug Handbook revealed [MEDICATION NAME] was an opioid [MEDICATION NAME] used for the treatment of [REDACTED]. Physicians orders dated 1/22/13 revealed [MEDICATION NAME] HCl (10 mg) 20 mg Tablet by mouth - Two times a day Every day: 20 mg PO (orally) BID (twice a day) and [MEDICATION NAME] HCl (10 mg) 15 mg Tablet by mouth - Two times a day Every day: 15 mg PO BID for pain. Review of the Resident 64's Medication Administration Record [REDACTED] - 12/6/12: 20 mg at 11:00 PM; - 12/21/12: 15 mg at 5:00 PM; - 12/24/12: 20 mg at 11:00 PM; - 12/31/12: 15 mg at 5:00 PM; - 1/1/13: 20 mg at 11:00 PM; - 1/3/13: 20 mg at 11:00 PM; - 1/6/13: 20 mg at 11:00 PM; - 1/7/13: 20 mg at 11:00 PM; - 1/11/13: 20 mg at 11:00 AM; and - 1/30/13: 15 mg at 11:00 PM. During an interview on 3/19/13 at 11:05 AM, the Director of Nursing (DON) revealed a review of Resident 64's narcotic (Narc) count sheet had no documentation on 1/22/13 that the [MEDICATION NAME]'s 11:00 AM dosage had been administered. The DON stated the Narc count sheet was showing that the [MEDICATION NAME] was not given. During an interview 3/19/13 at 1:38 PM, the Assistant Director of Nursing (ADON) stated review of Resident 64's Narc records for November 2012 through January 2013, revealed a 10 mg tablet had been signed out, but not the 5 mg tablet for the 15 mg dosage, 16 times, so (Resident 64) only got 10 mg instead of 15 mg. Also the ADON revealed only 1 - 10 mg tablets had been administered instead of 2 (10 mg administered instead of 20 mg dosage) on 12/4/12, 12/10/12, 1/22/13, 1/23/13, and 1/24/13. Review of Resident 64's Progress Notes revealed: - 12/7/12 at 9:15 PM = does have pain daily; - 12/8/12 at 10:23 PM and 12/9/12 at 10:28 PM = Complains of pain to low back; - 12/11/12 at 9:43 AM = [MEDICATION NAME] taken 7 x (times) for break through pain in the past wk (week); - 12/12/12 at 6:59 PM = has severe pain daily; - 12/16/12 at 11:57 PM = Complains of pain to low back; - 12/20/12 at 1:43 PM = C/O (complaints of) chronic back spasms, and leg and hip pain; - 12/30/12 at 9:41 PM, 1/1/13 at 3:18 AM, and 1/5/13 at 8:39* AM = Complains of pain to low back, routine [MEDICATION NAME] and prn (as needed) [MEDICATION NAME] given; - 1/8/13 at 4:37 PM = did have increased pain earlier in the shift; - 1/12/13 at 1:14 PM = Complains of 6/10 (rating of pain on a scale with 10 being the worse) to lower back; and - 1/15/13 at 9:32 AM = cont. (continue) to have increase in pain. During an interview on 3/19/13 at 2:03 PM the DON revealed nurses would be expected to review the routine Narc sheets to be sure medications were administered as ordered. D. Resident 57 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 57's admission physician orders [REDACTED]. The physician also documented to administer the [MEDICATION NAME] until the INR (International normalized ratio-a test for anticoagulant medications) was greater than 2.0. (Normal levels are 2.0-3.0 for all indications and 2.5-3.5 to prevent systemic embolism). In addition, Resident 57's physician's orders [REDACTED]. Review of Resident 57's lab work dated 1/14/2013 revealed that the INR was 2.52 which the laboratory marked as high. The physician was notified and wrote no changes and to recheck the INR in 2 weeks. However, the facility failed to verify if the [MEDICATION NAME] was to be discontinued as the physician had ordered on [DATE] when Resident 57 was admitted to the facility. Review of Resident 57's MAR (Medication Administration Record) for January 2013 revealed that the [MEDICATION NAME] was administered on 1/15, 16, 17, 18, and 19/2013 without verification from the physician to ensure that the [MEDICATION NAME] was discontinued as originally ordered on [DATE] for an INR above 2.0. In addition, the [MEDICATION NAME] was also administered to Resident 57 on those same days. Review of Resident 57's Nurse's Notes dated 1/20/2013 at 2:20 PM revealed that the resident had developed problems with labored breathing and started coughing green thick mucus and blood clots about the size of a quarter. Resident 57's pupils started to dilate and documentation revealed that Resident 57 stated (gender) felt like (gender) was going to pass out. The Physician was notified and Resident 57 was transferred to the emergency room for evaluation where the resident was admitted . Review of a facility investigation dated 1/22/2013 regarding the medication error for Resident 57 revealed that when Resident 57 was admitted to the hospital on [DATE], the INR was 6.81 and on 1/21/2013, the INR was 8.06 with a [DIAGNOSES REDACTED]. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1) Inservice training with all licensed nurses on the correct procedure for taking off physician's orders [REDACTED].>2) Inservice training with all staff, licensed or certified, who administer medications regarding the process for discontinuing narcotics; 3) Implementation of a checklist to be used that includes the 6 steps on how to process a physician's orders [REDACTED].>4) Implementation of a process to verify new and discontinued physician's orders [REDACTED].>5) All resident medications were checked against current physician orders [REDACTED].>6) Inservice training with all nursing staff on the identification of a change in resident condition and how to respond in an emergency situation; and 7) Inservice training with all staff, licensed or certified, on Critical Charting documentation related to for ongoing monitoring of residents' health conditions. The immediacy has been removed, however, the deficient practice has not been totally corrected. Therefore, the scope and severity has been lowered to D. |
2016-09-01 |