cms_TN: 1561

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
1561 TENNESSEE VETERANS HOME 445270 PO BOX 10299 MURFREESBORO TN 37129 2019-08-14 759 D 0 1 NLRY11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to ensure 1 (#423) of 8 residents received medication as prescribed by the physician during medication pass observation. The findings include: Facility policy review, General Dose Preparation and Medication Administration, dated 01/01/13, revealed .facility staff should verify that the medication name and dose are correct .verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time .confirm that the MAR (medication administration record) reflects the most recent medication order . Medical record review of Resident #423's physician order [REDACTED].[MEDICATION NAME] Sodium Tablet 200 MCG (microgram), Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION], UNSPECIFIED, start date 8/9/19 . Medical record review of Resident #423's physician order [REDACTED].[MEDICATION NAME] Sodium Tablet 175 MCG Give 1 tablet by mouth in the morning for [MEDICAL CONDITION], Discontinued, end date, 8/8/19 . Medical record review of Resident #423's Medication Administration Audit Report dated 8/6/19 through 8/13/19 revealed .[MEDICATION NAME] Sodium Tablet 200 MCG given to Resident #423 on 8/13/19 at 6:11AM . Observation of Licensed Practical Nurse (LPN) #1 on 8/13/19 at 8:45 AM in Resident #423's room revealed LPN #1 administered [MEDICATION NAME] Sodium 175 MCG to Resident #423. Interview with LPN #1 on 8/13/19 at 4:57 PM at the West Hall nurse's station revealed the order for Resident #423's [MEDICATION NAME] was changed to be given daily at 6AM. Continued interview confirmed LPN #1 gave Resident #423 [MEDICATION NAME] 175 MCG at the 9 AM medication pass. Interview with the Director of Nusing (DON), the Assistant Director of Nursing (ADON) and the Assistant Director of Clinical Services on 8/14/19 at 5:00 PM in the DON's office revealed, when asked to explain the process of a medication dosage change, the ADON stated when a medication gets changed the nurse was to put the new order in the system and discontinue the old orders and the medication needs to be taken off of the cart immediately after the orders are changed; the nurse was to look at the EMAR (electronic medical administration record) while giving the medication to ensure the order is correct. Further interview revealed, when the DON was asked to review the active MEDICATION ORDERS FOR [REDACTED]. Continued interview when the surveyor showed the DON the empty medication packet that LPN #1 administered to resident #423 on 8/13/19 at 8:45 AM, the DON confirmed resident #423 was given the wrong dose at the wrong time resulting in a medication error. 2020-09-01