cms_TN: 4044

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.

Data source: Big Local News · About: big-local-datasette

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
4044 AHC WEST TENNESSEE TRANSITIONAL CARE 445187 597 WEST FOREST AVENUE JACKSON TN 38301 2016-11-22 514 D 1 0 IQ3911 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, closed medical record review and interview, the facility failed to document a change in a resident's condition and failed to document the administration of as needed (prn) medications or follow-up on effectiveness of the medication for 1 of 3 (Resident #1) sampled residents reviewed. The findings included: 1. The facility's Documentation policy documented, .Accurate and complete documentation is a critical aspect of every operation within a long term care nursing facility. This facility's policy is to document information timely and consistent with all applicable professional, legal and established standards and guidelines .Problems or a change in condition that develops must have nursing documentation on every shift for 3 days/72 hours or until the problem is resolved. Examples of new problems which would require every shift documentation are .Nausea and vomiting . 2. The facility's PHYSICIAN ORDER [REDACTED].Physician standing orders or protocol-based orders are pre-authorized orders conditioned upon the occurrence of certain clinical events .After determining the medication is appropriate, the nurse must document the medication on the eMAR. Effectiveness of the medication should also be documented on the eMAR . 3. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the emergency medical services (EMS) Patient Care Report dated 8/7/16, revealed EMS received the call from the facility for transfer of Resident #1 to the hospital at 2:12 PM, EMS arrived at the bedside at 2:17 PM and reached the hospital at 2:39 PM. Review of the hospital emergency room (ER) records dated 8/7/16, revealed the resident arrived in the ER with decreased responsiveness, skin cool and pale. She had agonal respirations and runs of ventricular fibrillation (fast irregular heart rhythm), and quickly declined into an asystole (no heart beat). The resident was pronounced dead on 8/7/16 at 2:50 PM due to cardiopulmonary arrest. Resident #1's (MONTH) (YEAR) Physician order [REDACTED].Start/Continue Standing Orders . The PHYSICIAN BASED-ORDERS documented, .VOMITING: .[MEDICATION NAME] ([MEDICATION NAME]) 12.5 mg (milligram) PO (by mouth)/PR (per rectum) every 4 hours PRN . The 24-HOUR REPORT OF PATIENT'S CONDITION AND NURSING UNIT ACTIVITY dated 8/6/16, which is not part of the residents' medical record but a nursing report for change of shift, documented, .(Named Resident #1) .PATIENT'S CONDITION - EVENING .NIGHT .pp (pain pill) given for chest soreness, 2 episodes of vomiting, [MEDICATION NAME] given (symbol for with) positive effect @ (at) 0430 (4:30 AM) . There was no documentation in Resident #1's Clinical Notes Report or in a DAILY SKILLED NURSE'S NOTE of the resident's nausea and vomiting, the administration of the [MEDICATION NAME], or if the medication was effective. Review of the (MONTH) (YEAR) eMAR revealed there was no documentation of the pain pill having been administered, or the effectiveness of the pain pill, and no documentation of the [MEDICATION NAME] or the effectiveness of the [MEDICATION NAME]. Telephone interview with the responsible nurse, Licensed Practical Nurse (LPN #1), on 11/17/16 at 3:56 PM, when asked if she had administered a pain pill and/or [MEDICATION NAME] to Resident #1, stated, .She (Resident #1) said she didn't feel good, she was dry heaving, her mouth was dry. We offered her po liquids. I gave her a pain pill because her chest was sore, then gave her [MEDICATION NAME] ([MEDICATION NAME]) . When asked if the medications should have been signed out on the eMAR, LPN #1 stated, Yes. When asked if the effectiveness of the medications should have been addressed, LPN #1 stated, Yes. The Clinical Notes Report dated 8/7/16 at 9:29 AM documented, .Spoke with family member concerning patient nausea and vomiting last night .explained to family about medicine to treat nausea and vomiting and standing order for prn [MEDICATION NAME] . Review of the (MONTH) (YEAR) eMAR revealed no documentation of the [MEDICATION NAME] being administered. There was no further documentation regarding Resident #1's condition related to the effectiveness of the [MEDICATION NAME] given for nausea and vomiting. Telephone interview with the responsible nurse, LPN #2, on 10/18/16 at 9:45 AM, when asked if Resident #1 had been given [MEDICATION NAME] during the day shift, LPN #2 stated, .One of the family members asked for nausea medication. I gave [MEDICATION NAME] per standing order . 2019-11-01