cms_UT: 44
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 44 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 684 | D | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review it was determined, for 2 of 43 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, one resident's leg was not monitored after a fall and increase in pain and one hospice resident did not receive his medications and had to be sent back to the hospital. The deficient practice identified for the change in condition was found to have occurred at a harm level. Resident identifiers: 37 and 171. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On 4/26/18 resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient was on the bed that she was not quite far enough on the bed when slide board was removed and pt (patient) slid from bed to floor and landed on her buttocks and did not hit her head. Vitals taken and within normal limits. Pt assess (sic) before transfer and pt is able to bend knees and toes have good ROM (range of motion) with a minor increase in pain. Pt is also able to move bottom half of legs with some difficulty but normal ROM for patient. Pt transferred back into bed and skin check done with a little patch of [DIAGNOSES REDACTED] to knee and no other injuries noted. ROM continues to be normal for patient when assessed in bed. Patient continues to c/o (complain of) minor increase pain to right lower leg, [MEDICATION NAME] 5-325 mg (milligrams) administered and tolerated well. MD notified of fall and [DIAGNOSES REDACTED] to knee and increase in pain. No new orders at this time. ADON (Assistant Director of Nursing) notified. Resident is comfortable in bed at this time and will continue to monitor. b. 1/24/18 at 17:56 (5:56 PM), (Recorded as Late Entry on 1/26/18 at 23:59 (11:59 PM), Continue to check on patient often, Pt states pain medications are helpful for right leg pain. No changes to ROM or pain noted at this time. Pt appears comfortable in bed at this time and eating dinner. Will continue to monitor. c. 1/25/18 at 5:50 AM, Alert and oriented x (times) 3. Res reports ongoing UTI (urinary tract infection) symptoms. F/U (follow up) UA (urinalysis) at lab at this time. Midline remains in place at RUE (right upper extremity) flush without difficulty. One person ext. (extensive) ass (assistance) with brief changes. No s/s (signs/symptoms) injuries r/t (related to) recent fall. No increased pain r/t fall. VS (vital signs) = WNL (within normal limits). No changes noted. d. 1/25/18 at 1800 (6:00 PM), Resident is resting in bed and denies pain r/t the witness (sic) fall on 01/24/18, no skin issue noted or reported during this shift, IV (intravenous) Tigecycline administered per ordered (sic), the IV line is in place and with IV dressing intact on right arm, flushed with NS (normal saline) without problems, VS taken with (temperature) 97.3, (pulse) 67, (respirations) 16, (blood pressure) 111/66 and O2 (oxygen) sats (saturations) 92%, fluids applied and encouraged. e. 1/26/18 at 5:38 AM, IV ABX (antibiotic) infusion and flushes without difficulty. Afebrile, alert and oriented x 2 this shift. C/O pain at Rt (right) leg r/t recent fall. Reports about a 5/10 because they just changed me. No falls on this shift. No OOB (out of bed) on this shift. All PO (by mouth) meds as ordered and prn (as needed) pain medications provided and effective for pain res (sic). Res checked frequently throughout shift. Resting quietly most of Noc (night). WCTM (Will continue to monitor). f. 1/26/18 at 18:51 (6:51 PM), Resident c/o'd (complained of) increasing pain to right knee during giving nursing care, the right knee is bigger than left. It (sic) reported to (Physician 1). New order from (Physician 1) to X-ray to right knee and hip. X-ray was called in. Resident continues on IV ABX to treat UTI, no s/s of ASE (adverse side effects) noted, VS taken with (sic) T (temperature) 97.6, P (pulse) 63, R (respirations) 16, BP (blood pressure) 105/59 and O2 sats 91% on O2 3L (liters) via NC (nasal cannula). IV line is in place and with IV dressing intact to right arm, and flushed with NS without problems. g. 1/26/18 at 19:15 (7:15 PM), Received report from day nurse. Portable x-ray in rout (sic) for x-ray of Rt. hip and LOE (lower extremity). Res (Resident) is alert and oriented x 2. Res reports no pain at this time unless moved. Res informed of coming procedure. h. 1/26/18 at 22:49 (10:49 PM), X-ray results received per fax. Poss. (possible) Fx. (fracture) at RLE (right lower extremity) . No documentation could be located in the medical record to show that resident 37's right lower leg had been continuously monitored for changes after the fall on 1/24/18 after resident 37 had an increase in pain. Additionally, the facility staff did not order an X-Ray for resident 37's right lower extremity until 1/26/17, two days after the fall on 1/24/18, even though resident 37 had reported to facility staff that she had an increase in pain. 3. Resident 171 was admitted to the facility on [DATE] on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 171's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:55 (3:55 PM), Patient (pt) admitted to (Name of Facility) for hospice and comfort care. Discharge dx (diagnoses): hepatocellular [MEDICAL CONDITION]. Depression and/or anxiety features due to general medical condition; [MEDICAL CONDITION]. Past medical hx (history): DM; [MEDICAL CONDITION]; GERD; dementia. Hx of Hep ([MEDICAL CONDITION]) C; chronic back pain; hepatic [MEDICAL CONDITION] in (MONTH) (YEAR); portal vein [MEDICAL CONDITION]; DM II; [MEDICAL CONDITION]; perpheral [MEDICAL CONDITION]; DGD (unknown); resltless (sic) leg syndrome; hearing loss; abdominal aortic aneurysm; [MEDICAL CONDITION]; claudication; kidney stones; hx of UTIs (urinary tract infections). Patient is under (Name of Hospice) care/MD (Medical Doctor: (Name of MD). b. 1/24/18 at 18:55 (6:55 PM), Pt is alert and oriented to self only. Pt arrived to facility via (Name of Transportation). Pt admitted with liver failure and [MEDICAL CONDITION]. Pat being admitted to hospice upon arrival .Pt c/o (complains of) some belly pain r/t [MEDICAL CONDITION] .Pt has a history of aggressive behaviors while at home but have diminished since starting [MEDICATION NAME]. c. 1/24/18 at 19:09 (7:09 PM), Recorded as late entry on 1/25/18 at 7:13 PM, Discussed with Hospice nurse medications that they were D/C (discontinued). Informed hospice nurse that we had no medications for this res (resident) and we were waiting for hospice to supply. RN a/t (sic)be surprised at this and stated she would make a phone call re (regarding) med (medication) delivery. d. 1/25/18 at 6:13 AM, No medications have been delivered for this res. (Name of Hospice) to supply medications. e. 1/25/18 at 16:15 (4:15 PM), Resident is alert and orient (oriented) to self, is confusion (sic) and wandering to hallway, resident's room and outside of building, no c/o pain, no s/s of SOB, skin is W/D/I (warm, dry and intact), VS taken with T 98.0, P 83, R 18, BP 105/59, O2 Sats 94% on RA (room air), ate 100% of breakfast, good eating and drinking. LN was unable to administered (sic) medications for resident d/t (due to) resident's hospice pharmacy did not delivery (sic) his medications. LN called the hospice at 07:30 AM and had not received his medications. Resident was transferred to ER of (Name of Hospital) fur further evaluation r/t high elopement risk. Resident's spouse, (Name of Hospital) were notified, and the spouse came and got all resident's belongings. A discharge and Transfer - Physician Discharge Summary revealed the following: discharge date - 1/25/18 Discharge Time - 1615 (4:15 PM) Significant Changes in Condition - Increased confusion, elopement risk Final Diagnoses/Condition Upon Discharge - Stable, discharged to (Name of Hospital) for eval (evaluation) and treatment. Review of physician's orders [REDACTED]. a. [MEDICATION NAME] 300 mg (milligrams) TID (three times daily) for [MEDICAL CONDITION] b. [MEDICATION NAME] 10 gm (grams)/15 ml (milliliters); 45 ml (30 grams total) TID for [MEDICAL CONDITION] c. [MEDICATION NAME] 1000 mg QD (every day) at dinner time for DM d. [MEDICATION NAME] 40 mg QD before breakfast e. [MEDICATION NAME] 25 mg QHS (bedtime) for [MEDICAL CONDITION] m/b (manifested by) episodes of uncontrollable anger f. [MEDICATION NAME] 25 mg QD for ascites g. [MEDICATION NAME] 550 mg BID for hepatic [MEDICAL CONDITION] h. [MEDICATION NAME] 10 mg rectally QD prn (as needed) i. Fleet Enema 19.7 gm/118 ml rectally QD prn j. Milk of Magnesia 400 mg/5 ml, administer 30 ml (2400 mg total) QD prn k. Tylenol 325 mg 2 tabs (650 mg total) Q 4 hrs prn for general pain The Medication Administration Record [REDACTED]. On 4/25/18 at 1:11 PM, an interview was conducted with the (Name of Hospice) receptionist. The (Name of Hospice) receptionist stated that resident 171 had been admitted under their care for hospice services and that resident 171 had been sent back to the ER because his medications had not been delivered. The (Name of Hospice) receptionist stated that she was unaware of the circumstances and would call me back. The (Name of Hospice) receptionist stated that they would have supplied an [NAME] (emergency) kit for resident 171 which contained [MEDICATION NAME] and [MEDICATION NAME]. On 4/25/18 at 1:55 PM, an interview was conducted with the facility DON and the facility Corporate Nurse (CN). The facility DON and the facility CN stated that they should have followed up on the medications and that going to a different pharmacy to get resident 171's medications would have been a good idea. The facility DON stated that they had actually paid for medications before for a resident when medications had not come in but did not think of that. On 4/25/18 at 2:38 PM, an interview was conducted with the Hospice RN (HRN). The HRN stated that they had no notification that the medications had not been delivered to the facility until the morning of 7/25/18. The HRN stated that they felt terrible. The HRN stated that they had either had a software failure or the nurse had not hit the send button when the medications were ordered and that their pharmacy never got the order for the medications. Cross Refer to F-689 and F-849 | 2020-09-01 |