cms_OR: 35

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
35 REGENCY GRESHAM NURSING & REHAB CENTER 385015 5905 SE POWELL VALLEY RD GRESHAM OR 97080 2019-05-06 760 D 1 1 9QV111 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 1 sampled residents (#287) identified with a medication error. As a result, Resident 287 received an antipsychotic medication on 10/28/18 and required admission to the hospital for monitoring. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in staff awareness and education to ensure accurate identification of residents and no further medication errors occurred. This incident was identified as meeting the criteria for past noncompliance. Findings include: The facility General Dose Preparation and Medication Administration policy, last revised 1/2013, included the following: -Staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Resident 287 admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. Resident 287 discharged from the facility in 10/2018. On 10/28/19 at 6:00 PM Staff 16 (CMA) erroneously administered [MEDICATION NAME] (an antipsychotic medication) 100 mg to Resident 287. Staff 16 realized her mistake and immediately reported the error to Staff 11 (LPN). Staff 11 evaluated Resident 287 and notified the physician, the resident and Resident 287's family. The physician directed Staff 11 to monitor Resident 287 for adverse effects and send the resident to the hospital for any change of condition. Resident 287 later became sleepy and Staff 11 sent the resident to the hospital for evaluation. In an interview on 4/30/19 at 3:40 PM Staff 11 (LPN) stated on 10/28/18 Staff 16 erroneously administered [MEDICATION NAME] 100 mg to Resident 287. Staff 11 stated she immediately evaluated Resident 287 and notified the physician, the resident and the resident's family. Staff 11 stated Resident 287 became less responsive and appeared sleepy and was sent to the hospital for evaluation. In an interview on 5/1/19 at 1:58 PM Staff 16 (CMA) stated on 10/28/18 she administered incorrect medication to Resident 287. She stated she realized her error and immediately reported to Staff 11 (LPN). Staff 16 stated Resident 287 was a new admit and a picture was not available and she identified Resident 287 by the room number. Staff 16 stated it was a mistake not to identify the resident by name and date of birth. Staff 11 stated she did not pass medications after the incident until she received two weeks of one on one training with Staff 37 (RN) and attended a four hour competency class for certified medication aides. Interviews conducted from 4/30/19 through 5/2/19 between the hours of 8:00 AM and 5:00 PM with Staff 4 (LPN), Staff 5 (LPN), Staff 6 (CMA), Staff 7 (CMA), Staff 8 (CMA), Staff 9 (CMA), Staff 10 (LPN), Staff 11 (LPN), Staff 12 (CMA), Staff 13 (CMA), Staff 14 (LPN), Staff 15 (RN) and Staff 16 (CMA) identified all staff interviewed were aware of the five rights of medication administration. All staff stated it was expected and proper procedure to identify the resident with a picture, name band, name and date of birth before administering medications. On 5/2/19 at 10:49 AM and 3:39 PM Staff 1 (DNS) confirmed the medication error occurred and Resident 287 was sent to the hospital for evaluation. Staff 1 stated a Quality Assurance process was immediately implemented which included placement of identification wrist bands on newly admitted residents. Additionally, a four hour CMA training course was offered and Staff 38 (Staffing Coordinator/CMA) conducted skills audits to ensure medication pass competency of CMA and LPN staff. Staff 1 reported there were no further medication errors since the 10/28/18 incident. This situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance at F760. 2. The noncompliance occurred after the exit date of the last standard recertification survey (10/6/17) and before the date of this survey (5/6/19). 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F760 as evidenced by: -No deficient practice found at F760 with additional sampled residents -Evidence the deficient practice was identified by the facility, brought to quality assurance and a plan of correction was implemented on 10/29/18 to place a name band on newly admitted residents and educate and reinforce protocol to accurately identify residents. -DNS, RN, LPN and CMA interviews indicated knowledge and awareness of expectations and protocol to accurately identify residents. 2020-09-01