cms_TN: 3468
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3468 | CHRISTIAN CARE CENTER OF MEMPHIS | 445522 | 6500 KIRBY GATE BOULEVARD | MEMPHIS | TN | 38119 | 2018-04-02 | 760 | E | 1 | 0 | JLWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to ensure 2 of 3 (Resident #1 and 5) sampled residents with physician ordered anticoagulant medication were free from significant medication errors. The findings included: 1. The facility's Emergency Pharmacy Service policy documented, Emergency pharmaceutical service will be available on a 24-hour basis. Emergency needs for medication will be met by using the facility's approved emergency drug kit (EDK) or special order from the pharmacy supplier . 2. Medical record review revealed Resident #1 was admitted to the facility 3/9/18 with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (anticoagulant medication) 70 milligrams (mg) subcutaneously twice daily at 6:00 AM and 6:00 PM. Review of the Medication Administration Record [REDACTED]. The nurse documented, .Held due to not available. reordered (Reordered) from pharm (pharmacy) . Observations in Resident #1's room on 3/26/18 at 5:15 PM, revealed the resident was alert and oriented to person and place and had difficulty speaking clearly and fluidly due to [MEDICAL CONDITION]. Paresis (weakness or paralysis) was noted on the resident's right upper and lower extremities. A family member was present and assisted during the interview with the resident's permission. There was no evidence of a negative outcome due to the missed dose of [MEDICATION NAME]. Interview with Resident #1 and a family member in the resident's room on 3/26/18 at 5:15 PM, this Surveyor was informed the resident had missed her 6:00 AM (morning) dose of [MEDICATION NAME] because it was not available in the medication cart and had to be ordered from pharmacy. Interview with the Complainant in the conference room on 3/26/18 at 8:05 PM, this Surveyor was informed the missed AM dose of [MEDICATION NAME] had been available in the facility's EDK but the nurse had failed to use the emergency supply. 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The nurse had documented on 3/18/18, .Held due to not available; pharmacy notified . On 3/20/18 the nurse had documented, .Held due to Not available . Observations in Resident #5's room on 3/31/18 at 10:45 AM, revealed the resident to be resting quietly in bed, eyes closed, respirations regular and unlabored. There was no evidence of a negative outcome due to the missed doses of [MEDICATION NAME]. Interview with the Director of Nursing (DON) in the conference room on 3/31/18 at 9:10 AM, when asked about availability of [MEDICATION NAME] in the EDK, the DON confirmed the medication was available, nurses were trained to use the EDK and were given an access code by the pharmacy during the new hire orientation period. Observations and interview with the Licensed Practical Nurse (LPN) Supervisor in the medication room on 3/31/18 at 11:00 AM, confirmed the EDK to be fully functional and [MEDICATION NAME] was available for administration if needed. | 2020-09-01 |