| 4954 |
NORRIS HEALTH AND REHABILITATION CENTER |
445303 |
3382 ANDERSONVILLE HIGHWAY |
ANDERSONVILLE |
TN |
37705 |
2016-04-25 |
514 |
E |
0 |
1 |
EMXX11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to maintain a complete and accurate medical record for 6 residents (#22, #178, #169, #17, #150, #125) of 42 residents reviewed. The findings included: Review of facility policy, Medication Administration, revised 6/08 revealed .Record the name, dose, route, and time of medication on the Medication Administration Record [REDACTED]. Review of facility policy, [MEDICAL CONDITION] Management, dated 2012 revealed .in accordance with state regulation: the Licensed Nurse will institute the appropriate Behavior Monitoring form associated with the drug category .To identify/target behaviors .document number of episodes of behaviors . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurse Practitioner's (NP) order dated 3/18/16 at 10:40 AM revealed [MEDICATION NAME] (opiate antidote) 1.6 mg (milligram) IM (intramuscular injection) now .[MEDICATION NAME] 1mg IM again now . Medical record review of a NP order dated 3/18/16 at 11:00 AM revealed .Give 2 mg [MEDICATION NAME] now. Medical record review of the 3/18/16 through 3/31/16 Medication Record revealed no documentation the resident had received the [MEDICATION NAME]. Interview with the Director of Nursing (DON), on 4/18/16 at 8:40 AM, in the DON's office confirmed there was no documentation on the 3/18/16 through 3/31/16 Medication Record the resident had received any [MEDICATION NAME] on 3/18/16. Telephone interview with Licensed Practical Nurse (LPN) #1 on 4/18/16 at 10:05 AM revealed LPN #1 had administered the [MEDICATION NAME] 1.6 mg IM to the resident on 3/18/16. Interview with the facility's Wound Care Nurse on 4/18/16 at 10:30 AM, in the DON's office revealed the Wound Care Nurse had administered [MEDICATION NAME] 1 mg IM and [MEDICATION NAME] 2 mg to Resident #22 on 3/18/16. Continued interview confirmed the Wound Care Nurse had not documented the administration of the [MEDICATION NAME] onto the 3/18/16 through 3/31/16 Medication Record. Medical record review revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of Physician's Telephone Orders dated 12/16/15 and timed 12:30 PM revealed .Start [MEDICATION NAME] 7.5 mg PEG (Percutaneous Endoscopic Gastrostomy) Q 8 hours scheduled .Start 1 mg SQ q 15 m (minutes) (before) wound care BID (twice a day) . Medical record review of Physician's Telephone order dated 12/31/15 and timed 1000 (10 AM) revealed .Change routine [MEDICATION NAME] before wound care to prn before wound care at current dose/route. Medical record review of the Medication Record dated 12/16/15-12/31/15 revealed no documentation the [MEDICATION NAME] 0.1 ml had been administered 15 minutes before wound care. Continued review of the Medication Record revealed no documentation why the [MEDICATION NAME] had not been administered. Interview with the DON on 4/20/16 at 1:24 PM, in the conference room and review of the Medication Record confirmed the [MEDICATION NAME] was not documented as administered 12/16/15-12/31/15. Continued interview confirmed the facility failed to ensure complete documentation of the Medication Record. Medical record review revealed Resident #169 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #160 was discharged on [DATE]. Medical record review of the physician's orders [REDACTED]. 2 mg/ml (milliliters), 1 ml sq (subcutaneous) 10 min (minutes) b/f (before) wound care daily. Medical record review of the Medication Record dated 3/4/16 to 3/30/16 revealed no documentation of administration of [MEDICATION NAME] to Resident #169. Medical record review of the Controlled Drug Record dated 3/7/16 to 3/28/16 revealed [MEDICATION NAME] 2 mg/ml 1 ml sq b/f wound care was signed out 12 times. Interview with the DON on 4/22/16 at 9:50 AM, in the DON's office confirmed the [MEDICATION NAME] was not documented on the Medication Record from 3/4/16 to 3/30/16. Further interview confirmed the facility failed to ensure the medication record was complete. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Physician's Recapitulation Orders dated 7/17/15 revealed .[MEDICATION NAME] 5/325 (2) tabs po (by mouth) q (every) 6 (hours) as needed pain . Medical record review of a Prescription dated 7/24/15 revealed .[MEDICATION NAME] .5/325 mg 1 tab po QID (4 times daily) PRN (as needed) pain . Review of the Medication Variance Report dated 7/24/15 revealed .Medication Involved .[MEDICATION NAME] 5/325 .Original Medication Administration Record [REDACTED]. On 7/24/15 (Physician) wrote a new (prescription) for [MEDICATION NAME] 1 tab 5/325 po QID PRN/pain .order change for prescription not transcribed to MAR .Actions Taken Pt (patient) has received (2) tabs QID or Q 6 (hours) since admission (without) a change documentation reflecting new (prescription) . Medical record review of the Medication Administration Record [REDACTED]. Review of the Individual Patient's Controlled Substances Record revealed the following: 7/24/15-4 doses [MEDICATION NAME] signed out, 7/27/15-5 doses [MEDICATION NAME] signed out, 7/28/15-4 doses [MEDICATION NAME] signed out, 7/29/15-3 doses [MEDICATION NAME] signed out, 7/30/15-4 doses [MEDICATION NAME] signed out. Interview with the DON on 4/20/16 at 10:00 AM, in the DON's office confirmed the Prescription for the change in dosage of the [MEDICATION NAME] had been placed in the file bin and had not been discovered promptly. Interview with the DON on 4/21/16 at 12:45 AM, in the DON's office confirmed the documentation on the Medication Administration Record [REDACTED] Medical record review revealed Resident #17 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Record for 2/16 revealed: [MEDICATION NAME] (narcotic pain medication) 10 mg/325 mg 1 tablet by mouth 6 times daily with 2 doses not documented as administered. [MEDICATION NAME] Diskus ([MEDICATION NAME] inhaler) 250 mcg (micrograms)/50 mcg powder. Inhale 2 puff twice daily with 1 dose not documented as administered. Carvedilol (cardiac medication) 12.5 mg tablets,1 tablet by mouth twice daily with 2 doses not documented as administered. Duloxetine (antidepressant) HCL 60 mg capsule, 1 cap by mouth twice daily with 2 doses not documented as administered. [MEDICATION NAME] Sodium (low [MEDICAL CONDITION] medication) 125 mcg tablet, 1 tab by mouth every day with 1 dose not documented as administered. Medical record review of the Medication Record for 3/16 revealed: [MEDICATION NAME] (medication to lower blood pressure) 5 mg tablet, 1 tab by mouth every day with 1 dose not documented as administered. [MEDICATION NAME] (anti-psychotic medication) 10 mg tablet, 1 tab by mouth at bedtime with 5 doses not documented as administered. [MEDICATION NAME] (anti-depressant medication) HCL 150 mg tablet, 1 tab by mouth at bedtime with 5 doses not documented as administered. Carvedilol with 6 doses not documented as administered. Duloxetine with 5 doses not documented as administered. Medical record review of the Medication Record for 4/16 revealed: Carvedilol with 5 doses not documented as administered. Duloxetine with 4 doses not documented as administered. [MEDICATION NAME] with 4 doses not documented as administered. [MEDICATION NAME] (diuretic) 20 mg tablet, 1 tab by mouth every morning with 4 doses not documented as administered. [MEDICATION NAME] (steroid) 2.5 mg 1 po q am with 4 doses not documented as administered. [MEDICATION NAME] (anticonvulsant) 25 mg 1 po 1 am, on every even day x (times) 10 doses, the d/c (discontinue) with 4 doses doses not documented as administered. Interview with the DON on 4/21/16 at 9:05 AM, in the front office confirmed the medications for Resident #17 were not documented as administered for the months of 2/16, 3/16, and 4/16. Continued interview confirmed the facility failed to ensure complete and accurate documentation of the medication record. Medical record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] .50 mg tablet 1.5 (75 mg) tab by mouth every morning . [MEDICATION NAME] .0.25 mg 2 tabs (0.5 mg) by mouth every evening (10 PM) . [MEDICATION NAME] .0.25 mg 1 tab by mouth twice daily (8 AM & 4 PM) . Medical record review of the Behavior/Intervention Monthly Flow Record dated 4/1/16 revealed no documentation for behaviors on day shift or night shift for 4/11/16, 4/12/16, 4/13/16, 4/14/16, 4/15/16, and 4/17/16. Interview with LPN #10 on 4/20/16 at 10:06 AM, on the 100 Hall revealed .The nurses assess for behaviors every shift and we document the behavior or zero if the resident is not having any behaviors . Interview with the DON on 4/21/2016 at 8:55 AM, in the conference room confirmed the facility failed to document behaviors every shift for Resident #125. |
2019-06-01 |