cms_OR: 48
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 48 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2018-10-15 | 842 | E | 1 | 0 | EFS011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure records were accurate for 5 of 6 sampled residents (#s 2, 3, 7, 9 and 10) reviewed for medications. This placed residents at risk for inaccurate records. Findings include: 1. Resident 2 was admitted to the facility in 12/2016 with [DIAGNOSES REDACTED]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml give 0.25 ml every hour as needed for pain. Start 4/14/18 end 8/24/18 -[MEDICATION NAME] 20 mg/ml give 0.25 ml every four hours for pain. Start 6/28/18 end 9/19/18. -[MEDICATION NAME] 20 mg/ml give 0.5 ml every three hours for pain during awake hours. Start 9/19/18. Review of the 9/2018 and 10/2018 MAR and the Narcotic Drug Disposition Record (NDDR) revealed the following errors: - On 9/8/18 the MAR revealed the resident received six doses of 0.25 ml [MEDICATION NAME] every four hours. The NDDR record revealed the resident received four doses. -On 9/28/18 the MAR revealed the resident received seven doses of 0.5 ml [MEDICATION NAME] every three hours. The NDDR revealed the resident received eight doses. -On 10/6/18 the MAR revealed the resident received seven doses of 0.5 ml of [MEDICATION NAME]. The NDDR revealed the resident received six doses. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed they were to document on the MAR and narcotic book when they gave a narcotic to a resident. Staff 7 indicated she tried to be as accurate as she could. On 10/10/18 at 1:20 PM Staff 2 (DNS) indicated they were aware staff were not always double documenting and they tried to be as accurate as possible. 2. Resident 3 was admitted to the facility in 11/2006 with [DIAGNOSES REDACTED]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml 0.5 ml three times a day for pain. Review of the 8/2018, 9/2018 and 10/2018 MAR and the Narcotic Drug Disposition Record (NDDR) revealed the following errors: -On 8/13/18 the MAR revealed the resident received three doses of 0.5 ml [MEDICATION NAME]. The NDDR revealed the resident received two doses. -On 9/9/18 the MAR revealed the resident received three doses of [MEDICATION NAME]. The NDDR revealed the resident received two doses. -On 10/3/18 the MAR revealed the resident received three doses of 0.5 ml [MEDICATION NAME]. The NDDR revealed the resident received two doses. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed Staff 7 they were to document on the MAR and narcotic book when they give a narcotic to a resident. Staff 7 indicated she tried to be as accurate as she could. On 10/10/18 at 1:20 PM Staff 2 (DNS) indicated they were aware staff were not always double documenting and they tried to be as accurate as possible. 3. Resident 7 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml give 1 ml every hour as needed for pain. Review of the 9/2018 MAR and the Narcotic Drug Disposition Record (NDDR) record revealed the following errors: -The NDDR with a start date of 9/14/18 and end date of 10/5/18 had numerous scratch outs and staff wrote over existing numbers rendering the document inaccurate. -On 9/26/18 the facility documented on the NDDR they gave the resident .25 ml of [MEDICATION NAME] instead of the 1 ml. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed Staff 7 they were to document on the MAR and narcotic book when they give a narcotic to a resident. Staff 7 indicated she tried to be as accurate as she could. On 10/10/18 at 1:20 PM Staff 2 (DNS) indicated they were aware staff were not always double documenting and they tried to be as accurate as possible. 4. Resident 9 was admitted to the facility in 5/2017 with [MEDICAL CONDITION]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml give 0.25-1 ml as needed for pain. Review of the 9/2018 MAR and the Narcotic Drug Disposition Record (NDDR) record revealed the following errors: -On 9/15/18 the MAR revealed the resident received one dose of 0.25 ml [MEDICATION NAME]. The NDDR revealed there was no dose administered on 9/15/18. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed Staff 7 they were to document on the MAR and narcotic book when they give a narcotic to a resident. Staff 7 indicated she tried to be as accurate as she could. On 10/10/18 at 1:20 PM Staff 2 (DNS) indicated they were aware staff were not always double documenting and they tried to be as accurate as possible. 5. Resident 10 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. The resident had the following physician's orders [REDACTED].>-[MEDICATION NAME] 20 mg/ml give 0.25 ml every three hours as needed for pain. Review of the 9/2018 MAR and the Narcotic Drug Disposition Record (NDDR) record revealed the following errors: -On 9/7/18 the MAR revealed the resident received one dose of 0.25 ml [MEDICATION NAME]. The NDDR revealed there was no entry on 9/7/18 for the [MEDICATION NAME]. On 10/9/18 at 2:37 PM Staff 7 (CMA) revealed Staff 7 they were to document on the MAR and narcotic book when they give a narcotic to a resident. Staff 7 indicated she tried to be as accurate as she could. On 10/10/18 at 1:20 PM Staff 2 (DNS) indicated they were aware staff were not always double documenting and they tried to be as accurate as possible. | 2020-09-01 |