cms_TN: 15
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-01-18 | 602 | E | 1 | 0 | GSLM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to prevent misappropriation of resident's medication for 5 residents (#1, #3, #4, #5, and #6) of 9 residents reviewed for abuse. The findings included: Review of the facility policy Resident Rights - Abuse of Residents revised [DATE] revealed, .any type of resident abuse .or misappropriation of resident property is strictly prohibited .misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of a resident's belonging or funds without the resident's consent . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Medical record review of Resident #1's Physicians Orders revealed an order dated [DATE] for [MEDICATION NAME] (pain medication) 0.25 milliliters (ML) sublingual (under the tongue) as needed (PRN) every 1 hour for pain. Continued review revealed the order was discontinued on [DATE]. Further review revealed an order dated [DATE] for [MEDICATION NAME] 0.5 ml sublingual PRN every 3 hours as needed for pain. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #3 was moderately cognitively impaired. Medical record review of the Physician Orders revealed an order for [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #4 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating Resident #4 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 2 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 2, indicating Resident #5 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML sublingual every 4 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #6 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 0 (zero), indicating Resident #6 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 4 hours as need for pain. Review of a facility investigation dated [DATE] revealed the facility became aware of a possible drug diversion at approximately 11:45 PM on [DATE]. Further review revealed during the narcotic count at shift change between 2nd and 3rd shift, Licensed Practical Nurse (LPN) #3 observed a vial of [MEDICATION NAME] prescribed for Resident #1, which appeared to have the tamper resistant seal altered. Continued review revealed the vial was full as if no medication had been administered. Further review revealed LPN #3 immediately notified LPN #2, the night shift supervisor, of her concern and at that time LPN #2 immediately notified the Director of Nursing (DON). Continued review revealed the vial of [MEDICATION NAME] was delivered to the facility the afternoon of [DATE] and Resident #1's Medication Administration Record [REDACTED]. Continued review revealed on [DATE] the DON began a facility wide investigation. Further review revealed during a narcotic audit the facility identified 3 additional residents' (#4, #5, and #6) vials of [MEDICATION NAME] were altered. Further review revealed, after reviewing the staffing assignment sheets and schedules, the facility was able to identify Registered Nurse (RN) #1 provided care to, and had access to, the residents' medications. Further review revealed on [DATE], during the facility's monthly narcotic waste, the DON and the Pharmacist found a vial of [MEDICATION NAME] prescribed for Resident #3, which had been placed in the narcotic waste bin after the order was discontinued on [DATE]. Continued review revealed the vial of [MEDICATION NAME] was noted to have been altered. Further review revealed the DON reviewed the staffing assignment sheets and RN #1 provided care to Resident #3 on [DATE], the day the [MEDICATION NAME] was discontinued. Review of the police report dated [DATE] revealed .responded to (facility) in reference to a theft of medication .advised (RN #1) .had stolen liquid [MEDICATION NAME] from four different residents at the facility. (RN #1) stole the medication .While on scene I observed a bottle of [MEDICATION NAME] that had been diluted .(RN #1) was subjected to a drug screen, in which the first sample showed invalid due to the temperature of the urine at the time. (RN #1) was subjected to a second drug screen, in which she tested positive for [MEDICATION NAME] . Continued review revealed RN #1 admitted to stealing the [MEDICATION NAME]. Review of the Urine Drug Screen Laboratory Report dated [DATE] revealed RN #1 was positive for [MEDICATION NAME]. Interview with RN #1 via phone on [DATE] at 10:33 AM, confirmed she had taken [MEDICATION NAME] from various residents over a two week period in (MONTH) (YEAR). Continued interview confirmed she was unable to identify the residents specifically. Interview with the DON on [DATE] at 9:16 AM, in the conference room, confirmed she was made aware of possible drug diversion on [DATE] at approximately 11:45 PM by LPN #2. Further interview confirmed LPN #2 reported the vial of [MEDICATION NAME] ordered for Resident #1 was delivered to the facility on [DATE], the tamper resistant seal showed signs of having been tampered with, and Resident #1's MAR indicated [REDACTED]. Continued interview confirmed during the course of their investigation the facility identified 4 additional residents (Residents #3, #4, #5, and #6) whose vials of [MEDICATION NAME] were altered. Further interview confirmed after reviewing the staffing assignment sheets and schedule, the facility was able to determine RN #1 provided care to the affected residents. Continued interview confirmed initially RN #1 denied having any knowledge of the altered [MEDICATION NAME] but eventually admitted to the misappropriation of the [MEDICATION NAME]. Further interview confirmed RN #1 was suspended on [DATE] and remained on suspension until being terminated on [DATE]. Interview with the DON on [DATE] at 10:10 AM, in the conference room, confirmed through the facility's investigation they were able to identify RN #1 had taken [MEDICATION NAME] from 5 residents (Residents #1, #3, #4, #5, and #6) and the facility had failed to prevent misappropriation of resident's medication. | 2020-09-01 |