cms_SD: 33
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 33 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2019-03-13 | 554 | D | 0 | 1 | 0JC611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure two of two sampled residents (23 and 27) who self-administered medications had been assessed. Findings include: 1. Observation and interview on 3/11/19 at 3:30 p.m. with resident 23 revealed she had a unit dose [MEDICATION NAME] nebulizer treatment in her hand. She stated the nurse would give her the unit dose before it was due to be taken. She also had a [MEDICATION NAME] hand held inhaler, saline nasal spray, and [MEDICATION NAME] nasal spray on her overbed table. She stated she also self-administered those medications. Review of resident 23's medical record revealed: *She only had an order to self-administer her [MEDICATION NAME]. *The last self-administration assessment had been completed on 3/1/18. Review of resident 23's care plan for self-administration of medications initiated on 5/18/16 revealed: *Focus: I am able to self administer my nebulizer medication. *Goal: I will demonstrate my ability to correctly document and self administer my nebulizers through the next quarter. *Interventions included: I will participate in quarterly self administration assessments to qualify me to continue my self administration privileges. Interview on 3/13/19 at 1:29 p.m. with the Minimum Data Set (MDS) coordinator agreed no assessments had been completed since 3/1/18. The director of nursing and herself had changed the process, so the nurses were assigned that assessment. She stated the timing of the assessments was placed in the treatment administration record (TAR). When she looked on resident 23's (MONTH) and (MONTH) 2019 TARs those assessments did not show up to complete them. She agreed there was only a physician's orders [REDACTED]. 2. Observation on 3/12/19 at 8:04 a.m. of unlicensed assistive personal (UAP) A while she administered medication to resident 27 revealed: *She:-Left two [MEDICATION NAME] 80 milligram (mg) tablets in a plastic medication cup on his table. -Stated He will take them later. We can leave these medications with him. *A clip board on the overbed table with medication administration records (MAR) clipped on it. -UAP A stated the resident was supposed to keep track of when he took the [MEDICATION NAME] tablets on the MAR. -There had been no documentation of the medication times on that MAR. Review of resident 27's last reviewed 3/11/19 care plan revealed he had a [MEDICATION NAME] gel ordered 2/19/19 that he applied himself. There had been no order or assessment for self-administration of that medication. Review of resident 27's 3/16/16 physician's orders [REDACTED]. nursing to check weekly for accuracy. Review of the MDS Coordinator's 10/22/18 progress note revealed resident 27 had continued to self-administer medications. He had been able to review his process with her. There had been no self-administration assessment completed at that time. Review of resident 27's medical record revealed a self-administration for medications assessment had been completed on 1/26/18. There had been no others completed. Interview on 3/13/19 at 3:55 p.m. with the director of nursing (DON) confirmed resident 27 had not been:*Assessed on a regular basis for self-administration of medications. *Documenting on the MAR indicated [REDACTED]. 3. Review of the provider's 9/17/15 Self-Administration of Drugs, Medications and Treatments policy revealed: *Our facility permits residents to self-administer their drugs, medications and treatments unless such practice for the resident is deemed unsafe. *The assessment must be completed and a recommendation from the IDT (interdisciplinary team) to the provider made before the resident may exercise self-administration. *If is was determined the resident can carry out self-administration of medication an order will be obtained. *The resident is responsible for documentation of the medications they are self-administering. *The self-administration right is subject to periodic e-evaluation:minimum of quarterly, and/or an significant change in the resident's ability to self-administer. | 2020-09-01 |