cms_UT: 48
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 48 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 755 | E | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 6 of 43 sample residents, that the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically medications were not available from the pharmacy for administration. Resident identifiers: 22, 37, 56, 63, 163 and 165. Findings include: 1. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 resident 56's Medication Administration Record [REDACTED] For (MONTH) (YEAR), resident 56 had the following physician orders: a) [MEDICATION NAME], 1/4/18-1/28/18, 5 mg(milligrams)/mL (milliliter), amount to administer: 0.25 mL; oral, every 6 hours The order was changed to the following: [MEDICATION NAME], 1/28/18-1/30/18, 10 mg/5L, amount to administer 1 mL=2 mg; oral, every 8 hours. The medication was not available on the following dates: a) 1/4/18 at 6:00 PM Not administered: Drug/item unavailable. Comment: Notified hospice. b) 1/5/18 at 12:00 AM Not administered: Other. Comment: med not available; will f/u w/ hospice. c) 1/5/18 at 6:00 AM Not administered: other. Comment: med not available; will f/u w/ hospice. d) 1/5/18 at 12:00 PM Not administered: Drug/Item unavailable. Comment: Notified hospice, administered prn pain medication. e) 1/29/18 at 8:00 AM Not administered: Other. Comment: Hospice to deliver. f) 1/30 at 12:00 AM Not administered: drug/item unavailable. Comment: day nurse reported contacting hospice. Resident also reported contacting them. Not sent to facility. On 1/30/18 at 3:00 AM, a nursing progress note revealed, Resident activated call light and asked after the status of his Methadose (sic). Nurse reported that he has been having conversations with hospice .and that he is trying to get the situation resolved ASAP (as soon as possible). Resident stated that he will be making another (following on the night of 29 Jan) angry phone call in the morning if it does not arrive. Resident in the mean time requested/received/accepted PRN (as needed) [MEDICATION NAME] and [MEDICATION NAME] and stated he was going to try to get some sleep . For (MONTH) (YEAR), resident 56 had the following physician orders: a) [MEDICATION NAME], 1/30/18-2/20/18, 10 mg/mL, amount to administer: 0.2 mL (2 mg); oral, every 8 hours. The order was changed to the following: [MEDICATION NAME], 2/20/18-3/8/18, 10 mg/mL, amount to administer 0.3 mL ( 3 mg); oral, every 8 hours) b) [MEDICATION NAME] 10 gram/15 mL, amount to administer 30 mL; oral, every 6 hours c) [MEDICATION NAME], 200 mg (milligrams); oral, once a day The medications were not available on the following occurrences: a) 2/12/18 [MEDICATION NAME] Not administered Drug/item unavailable. Comment: pharmacy called, will deliver today. b) 2/19/18 [MEDICATION NAME] at 12:00 AM Not administered: Comment: Notified[NAME]with Bristol Hospice. c) 2/19/18 [MEDICATION NAME] at 8:00 AM Not administered: Drug/Item unavailable hospice called and notified. d) 2/20/18 [MEDICATION NAME] at 8:00 AM Not administered: Drug/Item unavailable. Comment: awaiting pharmacy, notified hospice. e) 2/20/18 [MEDICATION NAME] at 4:00 PM Drug/Item unavailable. Comment: awaiting pharmacy, notified hospice nurse. On 4/30/18 an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that some of the occurrences shouldn't have happened because the facility did have the medication available. The DON stated that they likely happened due to new nurses or agency nurses who were unfamiliar with the system and building. 2. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. physician's orders [REDACTED]. a. 1/16/18 through 1/22/18, [MEDICATION NAME] 1 gram; intravenous (IV) once a day for UTI (Urinary Tract Infection). b. 12/1/16, [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) subcutaneous at Bedtime. c. 1/6/18, [MEDICATION NAME] 100 mg Three Times a Day (TID) for [MEDICAL CONDITION]. The Medication Administration Record [REDACTED] a. On 1/16/18, [MEDICATION NAME] 1 gram IV was not administered to resident 37 due to waiting on med (medication) from pharmacy. b. On 1/8/18 and 1/14/18, [MEDICATION NAME] 20 mg injection was not administered due to Drug/Item unavailable. c. On 3/10/18, [MEDICATION NAME] 100 mg was administered at 16:19 (4:19 PM), 2 hours and 19 minutes after it was due, due to Drug/Item unavailable. 3. Resident 163 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 163's medical record was reviewed. physician's orders [REDACTED]. a. 10/13/17, Eliquis 5 mg twice a day at 8:00 AM and 8:00 PM for A-fib ([MEDICAL CONDITION]). The MAR for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following: c. Eliquis 5 mg not administered on 11/24/17 at 8:00 AM because med not avaialble(sic) notifeid (sic) pharmacy. 4. Resident 63 was admitted to the facility on [DATE] on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 63's medical record was reviewed. 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 1:55 PM, an interview was conducted with the facility DON (Director of Nursing) 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 63'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. The facility DON stated that medications should always be available to the residents. 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. 5. Resident 165 was admitted to the facility on [DATE] at 17:40 (5:40 PM) on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 165's medical record was reviewed. Nursing progress notes revealed that resident 165's medications were unable to be administered as they had not been delivered from the hospice company. Physician orders [REDACTED]. a. [MEDICATION NAME] 5 mg QD at 8:00 AM b. Bumetadine 1 mg 3 tablets (3 mg total) BID c. [MEDICATION NAME]-Salmeterol 250-50 mcg (micrograms) 1 puff inhalation BID d. [MEDICATION NAME]-[MEDICATION NAME] Nebulizer 0.02% BID e. [MEDICATION NAME] 25 mg QD at 8:00 AM f. Potassium Chloride 20 mEq (milliequivalant) QD at 8:00 AM The MAR for resident 165 for (MONTH) (YEAR) revealed the following: a. 11/11/17 at 8:00 AM - [MEDICATION NAME] 5 mg Not Administered: Drug unavailable, Hospice notified. b. 11/11/17 at 8:56 AM - Bumetadine 1 mg 3 tablets Not Administered: Drug unavailable, Hospice notified. c. 11/10/17 at 8:00 PM - [MEDICATION NAME]-Salmeterol 250/50 mcg Not Administered: Drug Unavailable. d. 11/11/17 at 8:00 AM - [MEDICATION NAME]-Salmeterol 250/50 mcg Not Administered: Drug unavailable, Hospice notified. e. 11/10/17 at 8:00 PM - [MEDICATION NAME]-[MEDICATION NAME] Nebulizer 0.02% Not Administered: Drug Unavailable. f. 11/11/17 at 8:00 AM - [MEDICATION NAME]-[MEDICATION NAME] Nebulizer 0.02% Not Administered: Drug unavailable, Hospice notified. g. 11/11/17 at 8:00 AM - [MEDICATION NAME] 25 mg Not Administered: Drug unavailable, Hospice notified. h. 11/11/17 at 8:00 AM - Potassium Chloride 20 mEq Not Administered: Drug unavailable, Hospice notified. On 4/25/18 at 1:15 PM, an interview was conducted with the facility DON. The facility DON stated that resident 165 did not miss very many medications. The facility DON stated that the medications should have been here and accessible for the resident. 6. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 22's medical record was reviewed. physician's orders [REDACTED]. a. [MEDICATION NAME] 0.5 mg at bedtime (HS). The Medication Administration Record [REDACTED] a. 4/6/18, [MEDICATION NAME] 0.5 mg was not administered due to not being available. Cross Refer F-757, F-760 and F-849 | 2020-09-01 |