| 95 |
LAS VEGAS POST ACUTE & REHABILITATION |
295006 |
2832 S. MARYLAND PARKWAY |
LAS VEGAS |
NV |
89109 |
2018-07-10 |
684 |
D |
1 |
0 |
1YJV11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and document review, the facility failed to document missed medications, transcribe physician orders [REDACTED].#1 and #2). Resident #1 Findings include: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 07/10/18 at 8:55 AM, the resident was alert, cooperative and able to express needs. A Sitter was observed by the door. 1) The admission orders [REDACTED]. The Antipsychotic Monthly Flow Record for (MONTH) (YEAR), documented to give [MEDICATION NAME] 600 mg. one tablet by mouth at hour of sleep. The document revealed the following: -06/13/18 to 06/17/18 were blank (no initials, no notes, no monitoring of behavior and side effects) -06/18/18 encircled initials with nurses notes awaiting pharmacy to deliver, monitoring for behavior and side effects documented. On 07/10/18 at 10:40 AM, a Licensed Practical Nurse (LPN) indicated the resident did not receive [MEDICATION NAME] for a few days after admission due to unavailability. The LPN indicated if the medication was not available the nurse should encircle his/her initials and document why it was not given. On 07/10/18 at 12:35 PM, the DON indicated expecting nursing staff to document on the Antipsychotic Flow Record whether or not the medication was administered. The DON indicated if the medication was not administered, the nurse encircled their initials and documented the reason for non-administration. The DON verbalized not being informed sooner of [MEDICATION NAME] not being available. The DON indicated not being familiar with [MEDICATION NAME] side effects and consequences of not being administered as prescribed. On 07/10/18 at 12:45 PM, the DON confirmed the resident did not receive [MEDICATION NAME] for six days, on 06/13/18, 06/14/18, 06/15/18, 06/16/18, 06/17/18 and 06/18/18. The DON confirmed this was not acceptable. The facility policy titled Administering Medications (revised (MONTH) 2012), documented the individual who did not administer the medication at the scheduled time shall initial and circle the space provided for the drug. 2) A physician order [REDACTED]. On 07/10/18 at 10:40 AM, a LPN indicated Resident #1's [MEDICATION NAME] dose of 600 mg Qhs was increased by 200 mg. The LPN verbalized 200 mg was given in the morning and 600 mg was given in the evening at hour of sleep. The Antipsychotic Monthly Flow Record documented to give [MEDICATION NAME] 200 mg one table take in the morning. The document reflected the dose was administered on 07/09/18 at 8:00 AM. The Antipsychotic Monthly Flow Record documented to give [MEDICATION NAME] 600 mg one tablet by mouth Qhs. The document reflected the dose was administered on 07/09/18 at 9:00 PM. On 07/10/18 at 1:25 PM, a Registered Nurse (RN) indicated the provider who wrote the order on 07/09/18 for 700 mg of [MEDICATION NAME] Qhs changed the order verbally (face-to-face) to increase the [MEDICATION NAME] to 800 mg, giving 200 mg in the morning and 600 mg in the evening. The RN indicated transcribing the latter into the Antipsychotic Monthly Flow Record. The RN verbalized she should have asked the provider to put the new order in writing but failed to do so. On 07/10/18 at 1:35 PM, the DON acknowledged the discrepancy between the written order ([MEDICATION NAME] 700 mg) versus the one transcribed into the Antipsychotic Flow Record ([MEDICATION NAME] 800 mg) and confirmed the administration of [MEDICATION NAME] 07/09/18 at 8:00 AM was not in accordance with the physician's orders [REDACTED].>Resident #2 Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 07/10/18 at 06/28/18, the resident laid in bed and had difficulty speaking but was able to communicate receiving therapy following a recent stroke. A physician order [REDACTED]. The Medication Administration Record [REDACTED]. On 07/10/18 at 3:00 PM, the DON explained the medication was available but the nurse who failed to administer the medication did not know the medication was kept in the refrigerator. The DON acknowledged [MEDICATION NAME] was not administered as scheduled and should have been. |
2020-09-01 |