| 69 |
SANDIA RIDGE CENTER |
325032 |
2216 LESTER DRIVE NE |
ALBUQUERQUE |
NM |
87112 |
2017-03-20 |
329 |
E |
0 |
1 |
30NH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents were free from unnecessary medications for 2 (R #s 3 and 70) of 5 (R #s 3, 58, 70, 99, and 110) residents reviewed for unnecessary medications by not completing behavior monitoring and pain assessments. This deficient practice has the potential to result in residents receiving unnecessary [MEDICAL CONDITION] (chemical substance that changes brain function and results in alterations in perception, mood, or consciousness) and pain medications, not receiving the right dose of a medication, and staff not knowing whether a medication is effective due to the lack of monitoring of pain and behaviors. The findings are: Findings for R #70: [NAME] Record review of the physcian's orders and admission face sheet indicated that R #70 had a [DIAGNOSES REDACTED]. R #70 is taking [MEDICATION NAME] (a medication for depression) 20 mg (milligrams) per day and [MEDICATION NAME] (antipsychotic medication) 50 mg every 8 hours for behaviors. B. Record review of a progress note dated 01/4/17 indicated that R #70 had a history of [REDACTED]. The note also stated that: 1. Resident exhibits behavior: Physical aggression as evidenced by: hitting, striking out, kicking, and pushing; 2. resists care or treatment, verbal aggression as evidenced by: yelling, cursing, insults to others; easily startled; 3. doesn't like when others talk to him; 4. combative/physically abusive with ADLS (activities of daily living); 5. He can be noncompliant/resistant to care. Hx (history) of suicidal ideation. Resident is very independent due to his military background and does not like getting help from staff. C. Record review of progress note dated 01/11/17, R #70 hit another resident while they were in the dining room near the coffee pot. Staff intervened and stopped R #70 of his aggression and both residents were separated. R #70 punched the other resident on his face and stomach. D. Record review of a progress note dated 03/01/17, indicated that R #70 was sitting in the dinning room at 1700 (5:00 pm) with another resd (resident) on (sic) his table drinking coffee. They got mad at each other for something and tried to hit. They were in physical contact but did not hit. They were separated from each other and were moved out of the dining room. E. Record review of the Behavior Monitoring Flowsheet for (MONTH) (YEAR) R #70 indicated that for the month of (MONTH) (YEAR), R #70 had a behavior monitoring sheet that was inaccurately filled by not having all of R #70's behaviors noted on the behavior sheet that they were monitoring. For the months of (MONTH) (YEAR) through (MONTH) 17, (YEAR) all of the behavior monitoring sheets were filled out inaccurately with no behaviors documented. There was no behavior monitoring sheet at all for R #70 for the month of (MONTH) (YEAR). F. Record review of the care plan dated 03/14/17 indicated that as an intervention for the use of [MEDICAL CONDITION] drugs, R #70 will have: 1. A behavior monitoring flowsheet completed and that monitoring for continued need of medication as related to behavior and mood. 2. Monitor for continued need of medication as related to behavior and mood. [NAME] On 03/15/17 at 3:22 pm, during an interview with Unit Manager #3, she stated that her expectation in documenting behaviors would be to document a behavior that was not the resident's baseline. They document behaviors by exception, so if someone was always cranky, then when they were cranky they wouldn't document that as a behavior. If they are on [MEDICAL CONDITION] medications all behaviors need to be documented on the behavior monitoring sheet. Otherwise a behavior from a resident would be documented in the progress notes. The behavior tracking sheet should be in the TAR (treatment administration record). H. On 03/16/17 at 11:25 am, during an interview with the DON (Director of Nursing), he stated that the behavior monitoring sheets from 09/01/16 to 02/28/17 for R #70 were incomplete. He also stated that it is agency staff that are not documenting the behaviors. I. On 03/15/17 at 2:10 pm, during an interview with LPN #6, she stated that R #70 easily get's angry with other residents, especially if they get in his way. He will sometimes become upset on his shower days. She stated that behaviors are documented by nursing staff and that CNAs or anyone else who might see behaviors should report them to the nurse. She stated that behaviors are being documented in the resident's medical chart but made no mention of the behavior monitoring sheets. Findings for R #3 Behavior Monitoring [NAME] Record review of the (MONTH) (YEAR) physician orders [REDACTED].> 1. [MEDICATION NAME] HCL ([MEDICATION NAME]) (narcotic pain reliever used to treat moderate to severe pain) tablet 5 mg (milligrams). Give 5 mg by mouth three times a day for pain. Order date of 01/06/17. 2. [MEDICATION NAME] HCL (antidepressant used to treat depression) tablet 25 mg. Give 1 tablet by mouth one time a day for depression. Order date of 02/23/16. 3. [MEDICATION NAME] (antidepressant used to treat depression) tablet 15 mg. Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION]. Order date of 01/06/17. 4. [MEDICATION NAME] (An antidepressent used to treat depression) tablet 20 mg. Give 20 mg by mouth in the evening related to dementia in other diseases classified elsewhere with behavioral disturbance. Order date of 04/27/16. K. Record review of R #3's Care Plan revised on 01/13/17 revealed: 1. Is at risk for complications related to the use of [MEDICAL CONDITION] drugs; Medication: [MEDICATION NAME], and [MEDICATION NAME]. 2. The goal is to have him have the smallest most effective dose without side effects for 90 days. 3. The interventions include monitor for continued need of medictation as related to behavior and mood, monitor for changes in mental status and functional level and report to MD (medical doctor) as indicated, monitor for side effects and consult physician and/or pharmacist as needed, and obtain psych (mental) evaluation as ordered. L. Record review of the Monthly Behavior Monitoring Flowsheets for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that flowsheets were blank without any documentation. Facility unable to provide flowsheet for (MONTH) (YEAR). M. Record review of the Progress notes dated 01/13/17 revealed resident can be verbally and physically agressive. He will also refuse care, especially showers. N. On 03/16/17 at 9:57 am, during interview the the DON, he stated the facility has new Behavior Monitoring and Intervention forms and they are to be charted by exception (charting only when a behavior occurs). He stated the forms for the months of (MONTH) (YEAR) and (MONTH) (YEAR) are incomplete because staff are not documenting refusals of care. He stated they have had agency staff working that have not filled out the forms correctly. He stated staff need training on filling out these Behavior Monitoring and Intervention forms correctly. Findings for R #3 Pain Assessment Documentation O. Record review of the Pain Assessment Medication sheet revealed: 1. Incomplete pain assessment for (MONTH) (YEAR) with 52 out of 78 missed opportunities where pain level is not documented. 2. Incomplete pain assessment for (MONTH) (YEAR) with 58 out of 84 missed opportunities where pain level is not documented. 3. Incomplete pain assessment for (MONTH) (YEAR) with 30 out of 44 missed opportunities where pain level is not documented. P. Review of the MAR (Medication Administration Record) for [MEDICATION NAME] HCL prescribed three times a day revealed incomplete pain assessments where pain level is not documented: 1. Pain assessment for (MONTH) (YEAR) with 53 out of 78 missed opportunities. 2. Pain assessment for (MONTH) (YEAR) with 83 out of 84 missed opportunities. 3. Pain assessment for (MONTH) (YEAR) with 41 out of 44 missed opportunities. Q. On 03/15/17 at 2:43 pm, during an interview with the DON, he stated pain assessments for R #3 should be done before each dose of [MEDICATION NAME] is given for pain, even if the dose is scheduled three times a day. He stated it should be documented in the MAR and he also stated it can be documented on the Pain Assessment Medication Sheet. He confirmed both the MAR and Pain Assessment Medication Sheet were incomplete without pain levels being documented. |
2020-09-01 |