| 8196 |
HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER |
425008 |
2601 FOREST DRIVE |
COLUMBIA |
SC |
29204 |
2013-02-21 |
329 |
D |
0 |
1 |
CSJ811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Recertification Survey, based on limited record review and interviews, the facility nursing staff failed to appropriately document behaviors for Resident #13 (1 of 16 sampled residents reviewed with psychoactive medications) relative to the administration of one time doses of Intramuscular (IM) [MEDICATION NAME] and [MEDICATION NAME] along with PRN (As Needed) doses of [MEDICATION NAME]. Resident #13 did not receive [MEDICATION NAME] as ordered x 2 doses after an ordered increase in dosage. The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. While in the facility, Resident #13 was diagnosed with [REDACTED]. Resident #13 was discharged home from the facility on 12/19/12. The closed chart was reviewed. Record review on 2/20/12 revealed a Physician's Telephone Order dated 11/22/12 at 1:00 PM which stated [MEDICATION NAME] 5 mg/ml (milliliter) IM now. The indication for the use of the [MEDICATION NAME] was documented on the order as having been for agitation. Review of the November 2012 Medication Administration Record [REDACTED]. Review of facility Progress Notes revealed a note dated 11/22/12 at 1:42 PM which stated, Resident is alert, responsive and up in w/c (wheelchair) at this time. No adverse reactions to medications, no c/o (complaints of) pain or distress noted on shift. Tx (Treatment) completed with no complications noted. No falls noted on shift. Peg tube patent, flushing and running at this time. VS (Vital Signs) 111/57, 98.7, 80, 20. RP (Responsible Party) notified of new order: [MEDICATION NAME] 5 mg/ml IM now, RE: agitation. There were no Progress Notes prior to this entry that documented any behaviors the resident was exhibiting, the severity of behavior, or an escalation in behaviors to indicate a need for the [MEDICATION NAME]. There was no documentation of any other interventions that had been attempted prior to the administration of the [MEDICATION NAME]. The resident had an order for [REDACTED]. Further review revealed a Physician's Telephone Order dated 11/22/12 at 7:00 PM which stated [MEDICATION NAME] 50 mg/ml now IM. The indication for use for the [MEDICATION NAME] was documented on the order as having been for agitation. Review of the November 2012 Medication Administration Record [REDACTED]. Review of Progress Notes revealed a note dated 11/22/12 at 9:58 PM which stated Resident is alert and responsive. HOB (Head of Bed) elevated to 45 degree angle. TF (Tube Feeding) infusing as ordered. Peg patent and flushes well. Resident ate 25% of meal on shift. No noted distress, no discomfort, no c/o (complaints of) pain. Tolerated meds by peg w/o (without) problems. No concerns voiced on shift. FSBS (Finger Stick Blood Sugar) -261, 4 units of [MEDICATION NAME] per ssi (sliding scale insulin). N.O. (New Order) [MEDICATION NAME] 50 mg/ml IM now given at 7 pm. There was no documentation in the Progress Notes to indicate the resident had exhibited any behaviors or what the agitation had been. During an interview on 2/20/13 at 1:30 PM, RN #1 (the Unit Manager) stated the resident had been sundowning and had been having behaviors right after dinner. After reviewing the above documentation with the surveyor, RN #1 verified that IM [MEDICATION NAME] and [MEDICATION NAME] had been given 11/22/12 for agitation (noted on the telephone orders) with no clear documentation that any behaviors had occurred. Review of a Behavior Assessment form in the hybrid medical record (computer) revealed a blank assessment (nothing documented) dated 11/21/12. Further review with RN #1 revealed there was no Behavior Assessment that addressed behaviors for 11/22/12. When asked, RN #1 stated that the Progress Notes, Medication Record, and the Behavior Assessments were the only behavior documentation the facility used. Review of Progress Notes revealed an entry dated 12/4/12 at 3:09 AM which stated Resident attempting to get up out of bed, [MEDICATION NAME] 0.5 mg one per peg given, brief wet assisted with adl (activities of daily living) care and did lie down, peg tube patent with Glucerna 1.5 infusing. Bed in lowest position. According to the Medication Administration Record, [REDACTED]. However, there was no clear documentation in the note that agitation had occurred and that the redirection of the resident with the brief change had not been a sufficient intervention in itself to get the resident to lie down. Further review revealed a Progress Note dated 12/18/12 at 12:28 AM which stated Alert and restless, legs hanging off bed, adl care given by cna (Certified Nursing Assistant), stated I'm going to my truck, [MEDICATION NAME] 0.5 mg one tab per peg given. Bed in lowest position. According to the MAR, an As Needed dose of [MEDICATION NAME] 0.5 mg had been given at 12:00 AM on 12/18/12. The Progress Note did not paint a clear picture of an agitated resident. The effectiveness of the [MEDICATION NAME] was not documented in the notes or on the Medication Record. During an interview on 2/20/13 at 2:15 PM, RN #1 agreed with the surveyor that the Progress Notes dated 12/4/12 and 12/18/12 were not clear pictures of an agitated resident. After reviewing the December 2012 Medication Administration Record, [REDACTED]. According to RN #1, (in reference to the Progress Note dated 12/18/12), when Resident #13 was focused on going somewhere, he/she was going. During an interview on 2/21/13 at 11:10 AM, the Director of Health Services (DHS) stated that nursing staff are so used to the residents having behaviors that they are not showing these behaviors through their documentation. Record review on 2/20/12 revealed a Physician's Telephone Order dated 11/27/12 which stated D/C (Discontinue) previous [MEDICATION NAME] orders. [MEDICATION NAME] 0.5 mg (milligrams) PO (By Mouth) or via peg (Percutaneous Endoscopic Gastrostomy) at AM (morning) and 1 mg PO or via peg at bedtime. The Indication-Dx (Diagnosis) listed on the order was Agitation/[MEDICAL CONDITION]. Review of the 11/20 - 11/30/12 Medication Administration Record [REDACTED]. There was nothing on the back of the Medication Record to indicate why the doses of [MEDICATION NAME] had not been initialed as having been given. During an interview on 2/20/13 at 2:08 PM, RN #1 stated that the Psychiatrist had written the order for the increased dosage of [MEDICATION NAME] on the evening of 11/27/12. She/He verified there were no initials to indicate that [MEDICATION NAME] 0.5 mg had been given for the morning of 11/28/12 or 11/29/12. RN #1 stated that since the order had been written on the evening of 11/27/12, the medication would not be sent to the facility by the pharmacy until the night of November 28th. The surveyor brought it to the nurse's attention that the medication had not been initialed as having been given on the morning of November 29th either. When asked if the nursing staff could have used the backup pharmacy to obtain the medication, RN #1 agreed that the nurses should have known to use the backup pharmacy. RN #1 stated an order should have been written to start the medication when available or the backup pharmacy should have been called to obtain the medication. According to RN #1 and the DON, the facility did not keep [MEDICATION NAME] in their emergency kit in the facility. The surveyor requested a pharmacy invoice to determine when the medication had been sent to the facility by the pharmacy, but this was not provided prior to exit. |
2016-06-01 |