cms_SD: 59
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 59 | WESTHILLS VILLAGE HEALTH CARE FACILITY | 435033 | 255 TEXAS ST | RAPID CITY | SD | 57701 | 2019-10-09 | 658 | D | 0 | 1 | G9N411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure: *One of one unlicensed assistive personnel (UAP) (A) had supervision of a registered nurse (RN) to ensure the prepackaged medication name received from the pharmacy matched the names on the Medication Administration Record [REDACTED]. *The blood glucose meter had been properly sanitized according to policy by one of one observed UAP (A). *There was a documentated rationale and specified duration for a PRN (as needed) [MEDICAL CONDITION] medication for one of four sampled residents (4) whose medical record was reviewed for unnecessary [MEDICAL CONDITION] medications and medication regimen review. Findings include: 1a. Observation on 10/9/19 at 8:04 a.m. of UAP A while she administered medications to resident 10 revealed the resident's packets of medications stated: *Sentry Senior take 1 tablet orally daily in the morning. *[MEDICATION NAME] 500 MG (milligrams) Take (2) tablets orally twice daily for pain. *There had been no matching medications listed on the resident's MAR for either of the above mentioned medications. b. Observation on 10/9/19 at 8:45 a.m. of UAP A while she administered medications to resident 15 revealed the resident's packets of medications stated: *Fiber-Lax Take 1 tablet by mouth twice a day.*Thera M Take 1 tablet by mouth every morning. *There had been no matching medications listed on the resident's MAR for either of the above mentioned medications. c. Interview on 10/9/19 at 8:55 a.m. with UAP A regarding the above for residents 10 and 15 revealed: *UAP A stated she: -Just knew Sentry Senior was the same as [MEDICATION NAME] Silver and [MEDICATION NAME] was the same as [MEDICATION NAME]. -Just knew Thera M was the same as a multivitamin and Fiber-Lax was the same as calcium polycarbophil 625 mg tablet twice a day. -Knew by process of elimination, because she poured all the residents other medications into the cups and these were the medicines remaining. -Just figured them out that way. -Had made the above decisions herself. -Had not asked a licensed nurse to confirm the above medications had been interchangeable. Interview on 10/09/19 at 9:50 a.m. with the consultant pharmacist confirmed the medication names on the packets of medications should match the MARs exactly. Interview on 10/9/19 at 10:00 a.m. with the director of nurses (DON) regarding the above confirmed the medication names on the packages should have matched the medication names on the MARs. Review of the providers 11/11/15 Medication Passing Procedure policy revealed: *Each nurse/med aide (UAP) will be responsible for all medications on their assigned wings. MAR indicated [REDACTED] *Each individual medication was to have been checked with the MAR for the right resident name, right medication, right dose, right time, right route, right effect, right form, and right documentation. Review of the provider's undated Med Aide job description and performance review revealed the medication aide would: Demonstrate proper administration of medication under the supervision of the licensed nurse. 2. Observation and interview on 10/9/19 at 10:21 a.m. with UAP A while she disinfected the blood glucose meter revealed she: *Wiped the blood glucose meter with a Sani-Cloth bleach wipe. *Stated it usually dried between one and one-half minutes to two minutes. *Often waited five minutes to be sure it was dry before she used it for the next resident. *Had been unaware of what the policy for cleaning of the blood glucose meter said to do. Interview on 10/09/19 at 10:40 a.m. with the DON regarding the glucometer disinfecting process confirmed UAP A had not followed their policy. She stated, We just covered about that. Review of the provider's (MONTH) (YEAR) Glucose Meters Cleaning and Disinfecting policy revealed: *The surface of the blood glucose meter was to have been wiped until completely wet. *Let stand for four (4) minutes, ensuring treated surface remains visibly wet. Use additional wipes if needed to assure continuous wet contact time. 3. Observation on 10/8/19 between 8:09 a.m. and 9:48 a.m. revealed resident 4 was in her room in bed asleep. Observation again at 10:06 a.m. revealed: *Nursing staff had changed the resident's [MEDICATION NAME]. -She was calm. *She was taken to the bathroom using a mechanical lift. -The resident voiced no concerns. Observation again at 1:24 p.m. revealed the resident was in a chair in her room watching television, and she voiced no concerns. Review of resident 4's 9/28/19 Minimum Data Set (MDS) assessment revealed: *Her [DIAGNOSES REDACTED]. *Her Brief Interview for Mental Status assessment score was fifteen indicating she was cognitively intact. Review of resident 4's (MONTH) 2019 through (MONTH) 2019 MARs revealed: *There was an order for [REDACTED]. -The start date of that order was 7/17/18. *The resident had used [MEDICATION NAME] three times on three separate days during (MONTH) for a jumpy leg, pain, and anxiety. *The resident had used [MEDICATION NAME] ten times on ten separate days during (MONTH) for anxiety, nervousness, concerns about dying, an appointment, and an inability to urinate. *The resident had used [MEDICATION NAME] six times on six separate days during (MONTH) for nervousness, anxiety, and sharp chest pains. *The resident had used [MEDICATION NAME] four times on four separate days during (MONTH) for anxiety, mild nausea, restlessness, and not feeling right. *The resident had used [MEDICATION NAME] one time during (MONTH) for not feeling good. *The use of PRN [MEDICATION NAME] had been documented as effective. Review of the 5/10/19 physician's visit progress note for resident 4 revealed: *Current resident medications had included [MEDICATION NAME] 0.5 mg. tablet, one tablet PRN orally every six hours. *Chief complaint: -Resident 4 is being seen for her regular recertification exam (examination), management of her chronic illnesses as listed in the past medical history, and for management of her medications. *Notes: -Continue with current care plan. Med list was reviewed with nursing home today. No changes were made. Review of the 7/15/19 physician's visit progress note for resident 4 revealed: *Current medications had included [MEDICATION NAME] 0.5 mg. tablet, one tablet PRN orally every six hours. *Chief Complaint: -Resident 4 is seen for her regular recertification exam, monitoring of her chronic illnesses as listed in the past medical history and for management of her medications. There's been no interval change in her health status. *Notes: -Continue with current care plan. Med list was reviewed with nursing home today. No changes were made. Review of the 9/19/19 physician's visit progress note for resident 4 revealed: *It was not yet completed or signed by the physician. *There was a signed and dated physician's orders [REDACTED]. -By signing below, I acknowledge the following: --Current orders have been reviewed and approved. --Current [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 through (MONTH) 2019 monthly Consultant Pharmacist's Progress Notes regarding resident 4's PRN [MEDICATION NAME] use revealed: *The consultant pharmacist recommendations created between 6/1/19 and 6/13/19 had included a record of the resident's use of PRN [MEDICATION NAME] use from (MONTH) (YEAR) through (MONTH) 2019. *The consultant pharmacist's recommendations between 7/1/19 and 7/12/19 revealed: -Consulted by nursing to evaluate pain and anxiety to develop a pain plan. Given the increase in both PRN [MEDICATION NAME] and [MEDICATION NAME] (pain medication) and that they are frequently given together or within 1 hour of each other they appear to be correlated. -The pharmacist advised the physician: the .last 2 times the [MEDICATION NAME] was increased there was a decrease in pain scores and PRN pain/anxiety medication usage. -There was no subsequent change made to the PRN [MEDICATION NAME] order by the physician. *The consultant pharmacist's recommendations between 8/1/19 and 8/13/19 and recommendation between 9/1/19 and 9/11/19 revealed there was no discussion regarding the resident's use of PRN [MEDICATION NAME]. Interview on 10/9/19 at 1:40 p.m. with the DON regarding resident 4's use of PRN [MEDICATION NAME] revealed: *She would have to review the resident's record to determine if there was physician documentation that had specified a duration of use for the PRN [MEDICATION NAME]. *She would have to review the resident's record to determine if there was physician documentation that had specified a rationale for extending the use of the PRN [MEDICATION NAME] beyond fourteen days. Interview on 10/9/19 at 2:23 p.m. with the administrator regarding resident 4's use of PRN [MEDICATION NAME] revealed: *There was no physician's documentation that had specified a duration of use for the PRN [MEDICATION NAME] or a rationale for extending the use of the PRN [MEDICATION NAME] beyond fourteen days. *She had referred the matter to the consultant pharmacist. Interview on 10/9/19 at 2:30 p.m. with the consultant pharmacist regarding resident 4's use of PRN [MEDICATION NAME] revealed: *He had no record he had contacted resident 4's physician about specifying a duration of use for the PRN [MEDICATION NAME]. *He had no record he had contacted resident 4's physician about documenting a rationale for extending the use of the PRN [MEDICATION NAME] beyond fourteen days. A copy of the provider's policy regarding PRN [MEDICAL CONDITION] Medication Use was requested on 10/9/19 at 3:15 p.m. from the DON. However the facility did not use such a policy, and no comparable policy was provided. | 2020-09-01 |