cms_UT: 29
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 |
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29 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 333 | D | 0 | 1 | AV3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not ensure that residents were free of significant medication errors for 2 of 32 sampled residents. Specifically, resident's did not receive insulin as ordered by the physician. Resident identifiers: 152 and 191. Findings include: 1. Resident 152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 152's medical record was reviewed on 8/17/16. A physician's orders [REDACTED]. If blood sugar less than 80 notify the Medical Doctor (MD), If blood sugar 80 to 140, give no insulin; If blood sugar 141 to 180, give 3 Units; If blood sugar 181 to 220, give 4 Units; If blood sugar 221 to 260, give 6 Units; If blood sugar 261 to 300, give 8 Units; If blood sugar 301 to 340, give 10 Units; If blood sugar 341 to 380, give 12 Units; If blood sugar 381 to 420, give 14 Units; If blood sugar greater than 420 notify the MD. A review of resident 152's (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) Medication Administration Record [REDACTED] a. On 6/11/16 at 7:00 AM, a blood sugar of 197 was documented. Resident 152 received 3 Units of insulin instead of the 4 Units per the sliding scale. b. On 6/12/16 at 7:00 AM, a blood sugar of 143 was documented. Resident 152 received no insulin instead of the 3 Units per the sliding scale. c. On 6/15/16 at 11:30 AM, a blood sugar of 143 was documented. Resident 152 received no insulin instead of the 3 Units per the sliding scale. d. On 6/24/16 at 9:00 PM, a blood sugar of 179 was documented. Resident 152 received 4 Units of insulin instead of the 3 Units per the sliding scale. e. On 7/3/16 at 7:00 AM, a blood sugar of 141 was documented. Resident 152 received 1 Unit of insulin instead of the 3 Units per the sliding scale. f. On 8/3/16 at 4:30 PM, a blood sugar of 143 was documented. Resident 152 received no insulin instead of the 3 Units per the sliding scale. 2. Resident 191 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 191's medical record was reviewed on 8/16/16. A physician's orders [REDACTED]. If blood sugar less than 80 refer to PRN (as needed) protocol and notify MD; If blood sugar 80 to 120, give 0 Units; If blood sugar 121 to 150, give 1 Units; If blood sugar 151 to 200, give 3 Units; If blood sugar 201 to 250, give 5 Units; If blood sugar 251 to 300, give 7 Units; If blood sugar 301 to 350, give 9 Units; If blood sugar 351 to 400, give 11 Units; If blood sugar 401 to 450, give 14 Units; If blood sugar greater than 450 notify the MD. A review of resident 191's (MONTH) (YEAR) MAR indicated [REDACTED]. Resident 191 received 0 Units of insulin instead of the 1 Units per the sliding scale. A physician's orders [REDACTED]. A review of resident 191's (MONTH) (YEAR) MAR indicated [REDACTED]. On 8/17/16 at 9:50 AM, an interview was conducted with the Director of Nursing (DON). No additional documentation was provide. On 8/17/16 at 11:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when a line was drawn on the MAR indicated [REDACTED]. On 8/17/16 at 12:05 PM, an interview was conducted with LPN 2. LPN 2 stated that the line drawn on the MAR means that no insulin was required per the sliding scale ordered by the physician. On 8/17/16 at 12:10 PM, an interview was conducted with LPN 3. LPN 3 stated that the line drawn on the MAR indicated [REDACTED]. | 2020-09-01 |