| 20 |
SANTA FE CARE CENTER |
325030 |
635 HARKLE ROAD |
SANTA FE |
NM |
87505 |
2019-07-19 |
759 |
E |
0 |
1 |
W7WU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure their medication error rate was less than 5% when they did not follow physician orders [REDACTED].#15, R #48, and R #96) out of 14 ( R #2, R #11, R #13, R #15, R #33, R #35, R #43, R #48, R #63, R #70, R #96, R #300, and R #303) residents reviewed during medication pass. This deficient practice results in the residents not receiving the medications as ordered by the physician and altering the desired therapeutic effect or exposing the resident to higher risk of experiencing side effects. The findings are: R #96 [NAME] Record review of the physician's orders [REDACTED]. B. Record review of the physician's orders [REDACTED]. Rinse mouth after administration, do no (sic) swallow. C. On 07/15/19 at 9:15 AM during observation of the medication pass, LPN #1 administered [MEDICATION NAME] Diskus 1 puff to R #96, then administered [MEDICATION NAME] HFA (a type of inhaler used to dilate the breathing tubes) one puff and almost immediately a second puff. LPN #1 did not assist the resident nor advise her to rinse her mouth with water and spit it out after using the [MEDICATION NAME] Diskus Inhaler. D. On 07/15/19 at 9:20 AM, during an interview with LPN #1 regarding the medication administration for R #96, she stated, No, it does not matter which inhaler she uses first. I did not know she needed to rinse her mouth after using a steroid inhaler. E. On 07/19/19 at 10:01 AM, during an interview with the ADON (Assistant Director of Nurses) regarding the inhaled medications for R #96, she stated, The nurse should have allowed a minute or two to pass between the [MEDICATION NAME] inhalations to get the best effect. She should have had the resident rinse her mouth and spit after the [MEDICATION NAME] inhaler. F. Review of [MEDICATION NAME] Diskus Package insert revealed: [MEDICATION NAME] can cause serious side effects, including fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using [MEDICATION NAME] to help reduce your chance of getting thrush. [NAME] Review of package insert for [MEDICATION NAME] Inhaler Glaxo[NAME]Kline (GSK) at www.[MEDICATION NAME].com. This Patient Information and Instructions for Use have been approved by the U.S. Food and Drug Administration Breathe out through your mouth and push as much air from your lungs as you can. Put the mouthpiece in your mouth and close your lips around it. Step 4. Push the top of the canister all the way down while you breathe in deeply and slowly through your mouth. Step 5. After the spray comes out, take your finger off the canister. After you have breathed in all the way, take the inhaler out of your mouth and close your mouth. Step 6. Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can. If your healthcare provider has told you to use more sprays, wait 1 minute and shake the inhaler again. Repeat R #15 H. Record review of the physician's orders [REDACTED]. I. On 07/19/19 at 7:47 AM during observation of the medication pass, RN #1 administered a pill to R #15 from a bubble pack labeled [MEDICATION NAME] (a medication used for treatment of [REDACTED]. (Each individual bubble has 1/2 pill in the bubble). [NAME] Record review of the MAR (Medication Administration Record) that RN #1 signed off as being given was labeled oxybutinin 5 mg tab po. K. On 07/29/19 at 7:50 AM, during an interview with RN #1, she stated, Yes the package is different from the MAR, but we all (all nursing staff giving medications) know she (R #15) gets just the [MEDICATION NAME] 1/2 pill. I only work 3 days a week and I expect the other nurses would let me know if there were any changes. L. On 07/19/19 at 10:01 AM, during an interview, the ADON stated, The nurse should have noticed the difference in the [MEDICATION NAME] dose and clarified the order before giving the medication. R #48 M. Record review of the physician order [REDACTED].>On 07/19/18 at 7:56 am, during observation of the medication pass, RN #1 administered a pill from a bubble pack to R #48. Record review of the pack revealed that it was labeled [MEDICATION NAME] 300 mg tablet. The Medication Administration Record [REDACTED]. N. On 7/19/19 at 8:10 am, during an interview, RN #1 stated, I see the package and the MAR indicated [REDACTED]. She affirmed she should have compared the MAR indicated [REDACTED]. O. On 07/19/19 at 10:01 AM, during an interview, the ADON stated, The nurse should have clarified the order and given the correct dosage. We have ranitadine over the counter in the medication, she could have used that and given the right dosage. P. Review of the bubble pack for R #48, labeled [MEDICATION NAME] 300 mg tablets revealed out of a 30 pill pack, 18 had been removed from the bubble pack. |
2020-09-01 |