cms_PR: 16
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 16 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2017-05-04 | 425 | D | 0 | 1 | ZOYB11 | Based on a recertification extended survey, drug pass, medication reconciliation, records reviewed (R.R.) and interviews with the Nursing Supervisor (Employee #4) and Registered Nurse (RN) (Employee #1 ) at the facility performed on 5/3/17 from 9:15 am thru 11:00 am, it was determined that the facility failed to provide a mechanisms to ensure that all received medications are accurate acquired, received, dispensed and administered to meet the resident (R) needs for 1 out 28 admitted residents. (Supplemental Sample Resident #11) Findings include: A lack of mechanism to ensure that the resident Medication Administration Record [REDACTED]. 1. According to MAR indicated [REDACTED] a. The physician order from 4/26/17 at 8:30 pm establishes Haldol 5 mg PO Bedtime (hours of sleep) (HS). However the nursing staff was administrating Haldol 5 mg 1 tablet PO Daily at 9:00 am since 4/29/17 thru 5/3/17 (5 days). No physician's order was found in the clinical record establishing that this medication will be given in the morning medication pass. During interview with RN (Employee #1) on 5/3/17 at 10:55 am, she stated: The original order is Haldol 5 mg 1 Tab PO at Bedtime. But this medication has been administered in the morning medication pass according to the MAR indicated [REDACTED]. During interview with the Nursing Supervisor (Employee #4) on 5/3/17 at 10:57am, she stated: The medication must be administered at bedtime, as the medical order indicates. It seems that there was a mistake in transcribing the order in the electronic MAR. 2. After interviewing the RN (Employee #1) who performed the drug pass and the Nursing Supervisor (Employee #4) performed on 5/3/17 at 10:55 am it was found that the facility failed to have an ongoing surveillance to avoid near future adverse effects from medication administration related to time error. This resident has been taking the medication for 5 consecutive days in a wrong timing and no one of the professional staff observed that issue. It was requested an investigation on 5/3/17 at 11:00 am and the Nursing Supervisor (Employee #4) delivered on 5/4/17 at 4:40 pm the medications error report with information related to the event. During review of the medications error report performed on 5/4/17 at 4:50 pm it was not found pertinent information in some sections of this report that shows if residents had side effects, if it was requested an ongoing monitoring of the resident to determine if she needed changes on treatment and a review of the plan of care by the nursing staff. a. On section I, it was not included the resident's diagnose, how many doses of Haldol were administered during the morning hours for 5 days and it was not signed and dated by the Nursing Supervisor. b. On section II, no evidence that the physician was notified due to space assigned to physician notification was left in blank, was not signed by the Nursing Supervisor, and no information was included when the event was notified to the Pharmacy Services. c. On section III, reasons for error was not identified . In section known as staff related to the event, it was not documented. In section known as side effects on the resident, it was not documented. | 2020-09-01 |