cms_SC: 10126
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10126 | FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2011-01-26 | 281 | D | ZGHV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on limited record review, observations and interviews, the facility failed to assure that licensed staff appropriately handled narcotics. Two licensed practical nurses (LPN) failed to appropriately count narcotics at the change of shift. Liquid [MEDICATION NAME] was left unattended on a resident's bedside table for an unknown period of time. That resident (Resident #2) was sent to the emergency room with a change in condition. The findings included: The facility readmitted Resident #2 on 3/10/2010 with [DIAGNOSES REDACTED]. Record review revealed the resident was receiving [MEDICATION NAME] 7.5/500 milligrams 1-2 tablets every 6 hours for pain. The resident was also receiving [MEDICATION NAME] for anxiety nightly. Residents #2 and #3 sampled as a result of a facility reported incident dated 1/9/2011 related to an allegation against Licensed Practical Nurses (LPN) #2 and #3. The initial 24 hours report stated, "medication left at bedside on Saturday 1/8/2011. A thorough investigation was implemented immediately. The incident was reported to the administration at 2:08 PM." Review of the 5 Day Follow Up dated 1/13/2011 revealed the alleged perpetrator as LPN #1. The Director of Nurses was notified on 1/8/2011 at 2:08 PM. The report indicated that the resident (#2) was last observed at 12:30 PM and was noted to be alert with increased congestion and thick green mucous. The Details of the Incident were "nurse in attending to resident and found liquid [MEDICATION NAME] at bedside. Due to change in resident's respiratory status earlier in the day and the potential ingestion of medication the resident was sent to the emergency room . The hospital was notified of the potential ingestion as a precaution. The intervention in place prior to the incident was "narcotics are counted and reconciled at shift change." Immediate corrective action taken was that LPN #1 was "suspended immediately and will not return to employment and license will be reported to LLR per protocol. 100% audit of narcotics in 4 of 4 medication carts was conducted. 100% of licensed staff was re-inserviced regarding securing and accounting for narcotics. Hazardous material re-inservice was done with 100% of staff." The Summary of Incident was "Nurse violated standard of practice related to securing medication." Review of the Timeline related to the incident provided by the facility revealed the resident was found lethargic and unintelligible at 1 PM per the nurse's notes. At 1:21 PM, the ambulance was called. At 1:27 PM the ambulance arrived at the facility (per the ambulance record). Per the nurses notes the resident left at 1:30 PM. According to the ambulance record the resident did not leave the facility until 1:58 PM and arrived at the hospital at 2:03 PM. LPN #1 notified the Director of Nursing (DON) at 2:08 PM of the [MEDICATION NAME] and incorrect narcotic count. LPN #1 also reported to the DON that Resident #2 was sent to the emergency room in respiratory distress. LPN #1 reported that 13.5 milliliters of liquid [MEDICATION NAME] were unaccounted for. The DON arrived at the facility at 2:30 PM. Drug tests were performed on all staff with potential contact with Resident #2 including LPN #1 and 2 and on two Certified Nursing Assistants. LPN #1 and #2's drug tests were negative. CNAs #1and #2 drug tests were positive; they were suspended. Review of the nurse's notes dated 1/8/2010 at 5:30 AM stated, "Resident coughing up thick green tinged sputum. Breathing trt (treatment) given. Congestion noted in upper lobes bilaterally. Will continue to monitor." On 1/8/2010 at 6:30 AM it was documented that "Breathing trt helped resident loosen mucous and has productive cough with green sputum." At 1PM, "Resident lethargic, unintelligible sounds noted, resp(iratory) distress noted. Spitting up green mucous. Talked with RP (responsible party) and she would like res(ident) sent to ER. (Doctor) notified and order received to send to ER for eval and treatment." At 1:30 PM the resident was sent to the ER via ambulance. Further review revealed no documentation of the resident's status between 6:30 AM and 1 PM, however review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Narcotic Count sheets on 01/26/2011, for Resident #3 (roommate of Resident #2) revealed [MEDICATION NAME] 20 mg/ml, 30 ml (milliliter) bottle. Line 48 indicated that LPN #1 signed out the [MEDICATION NAME] on 1/8/2011 at 2 PM. It was documented that 23.5 ml should have been left in the bottle. Review of the facility obtained statement for LPN #1 revealed that she and LPN #2 "counted narcotics this am (1/8/2011). I saw three bottles of [MEDICATION NAME] and glanced at them for content. I did not read labels with names. At 1:30 PM, I went to get Resident #3's [MEDICATION NAME] and could not find the bottle on the cart. I checked each drawer, narcotic box, and refrigerator and (the nurse) checked her cart. I(t) occurred to me that some nurses administer [MEDICATION NAME] with the dropper so. I immediately check res(ident) room and found bottle on bedside table of roommate (Resident #2). I had been in room several times this AM and did not see bottle (or notice bottle). Bottle of [MEDICATION NAME] had 10 ml when I found it. When we counted meds this AM, I looked at the meds and LPN #2 looked at the sheets." During an interview on 1/26/2011 at 12 PM, LPN #1 stated that during the narcotic count at shift change it was routine practice not to count the liquid medications because they were "always off." LPN #1 stated that she was giving [MEDICATION NAME] to another resident around 11:30 AM or 12 PM and noticed only three bottles of [MEDICATION NAME] were in the cart. She stated that she searched for the missing [MEDICATION NAME] in other drawers, medication room, refrigerator and the other med carts. She stated that it "occurred to her that nurses would use the medication dropper." She stated that she then went into Residents #2 and #3's room and found the [MEDICATION NAME] on Resident #2's bedside table. She stated that she immediately counted the medication and noticed it was off. She stated that the CNAs then reported to her that Resident #2 was unarousable. LPN #1 performed a sternal rub and notified the family and then the doctor. She stated that she assumed the resident consumed the medication. LPN #1 then stated that it was between 12 and 12:30 PM that she noticed the missing [MEDICATION NAME] and about 15-20 minutes later noticed Resident #2 was unarousable. LPN #1 stated that she did not obtain any vital signs and had administered the resident's breathing treatment. LPN #1 stated that she notified the family and then the doctor because that was the normal protocol. LPN #1 stated that she instructed the CNAs to "clean the resident up" before she was sent out. LPN #1 stated that during the narcotic counts at shift change, one nurse would look at the medication and one nurse would look at the sheets. She stated that both nurses did not visualize the medications. LPN #1 stated that it "was not an absolute necessity" for both nurses to reconcile the narcotics. LPN #1 stated that no other nurse had access to her cart that day. LPN #1 also stated that there was only one set of keys per cart. LPN #1 verified her facility obtained statement was correct as well as the statement reported to the surveyor. LPN #1 could not account for the discrepancies in the statement nor in the times of the events accounted. Review of LPN #2's facility obtained statement dated 1/8/2011 revealed that LPN #2 "counted off with first shift nurse. I stated amounts left in [MEDICATION NAME] bottles and she stated ok. I was looking at each narcotic sheet and did not visualize the narcotics as we were counting. I gave (Resident #3) her meds then her [MEDICATION NAME] set the [MEDICATION NAME] on (Resident) nightstand, started her breathing treatment. When (sic) to (Resident #2) to check on her, she asked for pain medicine. I went back to med cart to get (Resident's #2's) two [MEDICATION NAME] and breathing treatment. At the end of my shift I counted off with first shift nurse called amounts left in [MEDICATION NAME] bottles and she stated ok for each." During an interview on 1/26/2011 at 4:35 PM, LPN #2 stated that she was positive she replaced Resident #3's [MEDICATION NAME] back into the medication cart after she administered the [MEDICATION NAME] to her at 6 AM. LPN #2 stated that during the Narcotic count at shift change she was calling off the medications from the narcotic sheets and LPN #1 was counting the medications. LPN #2 stated that she visualized all 4 [MEDICATION NAME] bottles but didn't measure the contents. LPN #2 stated that LPN #1 didn't pick up any [MEDICATION NAME] bottles but both visualized all 4 bottles were present at shift change. LPN #2 stated that she normally reads the narcotic sheets and counts the medications. She stated that the other nurse picks up the liquid medications and would hold them up so both could visualize the amounts. LPN #2 stated that she "always counted liquid narcotics." LPN #2 verified the accuracy of her facility obtained statement and stated that both the statement given to the facility and the statement given to the surveyor were the same and accurate. LPN #2 again stated that she visualized the [MEDICATION NAME] bottles at shift change. LPN #2 could not account for the discrepancy in the statements. During an interview on 1/25/2011 CNA #1 stated that she was assigned to Residents #2 and #3 on 1/8/2011. She stated that she did not see the [MEDICATION NAME] bottle in the residents' room. CNA #1 stated that she was informed that [MEDICATION NAME] was missing by the DON and was drug tested . CNA #1 stated that her drug test was positive. CNA #1 stated that she had not been back to work since 1/8/2011 and stated that she had not been contacted by the facility since her suspension. During an interview on 1/25/2011, CNA #2 stated that she was working on 1/8/2011 but was not assigned to either Resident #2 or #3. CNA #2 stated that she was not aware of the missing [MEDICATION NAME] nor was she questioned regarding the incident. CNA #2 stated that she was drug tested and the test was positive. During an interview on 1/24/2011 at 12 PM, the DON stated that LPN #1 and #2 were suspended pending the conclusion of the investigation. The Director of Nursing (DON) stated that the facility was "still in the investigation process." During a follow up interview with the DON and the Administrator, the Administrator stated that the hospital was notified of the potential ingestion of [MEDICATION NAME]. The emergency room (ER) doctor stated that a Toxicology Screen was not performed because the resident was already prescribed narcotics. The ER doctor did state that [MEDICATION NAME] was given and the resident did "perk up a bit." The DON stated that both LPN #1 and #2 admitted to counting the narcotics incorrectly, the DON stated that both nurses should have visualized the narcotic as well as the narcotic sheet. The DON stated that LPN #1 reported that only 3 [MEDICATION NAME] bottles were in the cart at shift change even though 4 were recorded as present. The DON stated that she did not know what happened to the missing 13.5 ml of [MEDICATION NAME]. A Narcotic Count of liquid [MEDICATION NAME] was conducted on 1/24/2011 with the DON and the surveyor. Some of the [MEDICATION NAME] bottles were noted to have more than the recorded amount. The Narcotic sheets would record a number then a + sign to indicate the excess. The DON stated that the pharmacy was aware. The Pharmacy stated that the amount in the bottles was correct, however the curvature of the [MEDICATION NAME] bottles made it appear that there was more in the bottles. Review of the Controlled Medication Policy stated, "...there must be complete accountability of all controlled substances being stored at the facility. The nurse going off duty and the nurse coming on duty must count all controlled substances at the end of each shift." | 2014-04-01 |