cms_TN: 26
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 26 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 501 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Medical Director Contract, facility policy review, review of facility investigations, review of Consultant Pharmacists Reports, medical record review, and interview, the facility failed to ensure the Medical Director participated in the development and implementation of facility policies to ensure Physicians orders were followed, insulin was administered as ordered, and blood glucose levels were monitored and documented for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of the Medical Director Contract dated [DATE] revealed .SERVICES TO BE PERFORMED BY PROVIDER .Provide medical services in accordance with accepted professional standards of practice and use only qualified duly licensed, certified or registered health care professionals in the performance of these services .Responsible for the overall coordination of medical care at the Facility .shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident policies and providing oversight and supervision of medical services and medical care of residents .Evaluate and take appropriate steps to correct any problems associated with any possible inadequate care Provider identifies or about which Provider receives a report . Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Medical record review for Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Interview with the Medical Director (MD) on [DATE] at 8:00 AM, by phone, and on [DATE] at 8:00 PM, in the Director of Nursing (DON)'s office, confirmed the facility had a critical insulin error for Resident #1 on [DATE]. Continued interview confirmed she took this error to Quality Assurance (QA). The MD stated the goal of Quality Assurance (QA) was to look for the .etiology in errors . Continued interview confirmed there were not any pharmacy reports or major trends in insulin errors discussed in the QA meetings; .I felt we were doing pretty good . Further interview confirmed the MD did not receive copies of the monthly Pharmacy Reports. Further interview revealed the MD was involved in generating protocols and procedures regarding medication administration, but did not do inservices and was not involved in hitting the floor to monitor or audit for errors. Her expectations were education occurred. Further interview confirmed the Consult Pharmacist Reports indicated ongoing transcription errors of insulin orders, errors in administration of insulin, and missing documentation of blood glucose levels occurring in the facility in January, March, April, (MONTH) and (MONTH) (YEAR). Continued interview confirmed she was not aware of the Consultant Pharmacist Reports. Further interview confirmed the Medical Director was responsible for ensuring implementation of resident policies and providing oversight and supervision of medical services and medical care of residents. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F490 (E), F 514 (E), F520 (E) | 2020-09-01 |