| 50 |
MT OLYMPUS REHABILITATION CENTER |
465006 |
2200 EAST 3300 SOUTH |
SALT LAKE CITY |
UT |
84109 |
2018-04-30 |
760 |
E |
1 |
1 |
C87F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined that the facility did not ensure that 17 of 43 sample residents were free of significant medication errors. Specifically, multiple residents had medications that were not administered, received the wrong medication, were administered late or medications were not available. One resident received a double dose of [MEDICATION NAME]. Resident identifiers: 3, 4, 18, 20, 25, 30, 37, 45, 56, 59, 63, 163, 165, 166, 168, 169 and 263. Findings include: 1. 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. 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]. d. 3/5/18, [MEDICATION NAME] 3 mg on Sunday, Tuesday, Thursday, Saturday. 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. d. On 4/22/18, [MEDICATION NAME] 100 mg was Not Administered due to condition. e. On 4/22/18, [MEDICATION NAME] 3 mg was Not Administered, On Hold, Pt (patient) is very sleepy. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 4's medical record was reviewed. physician's orders [REDACTED]. a. 8/15/17, [MEDICATION NAME] 0.5 mg twice daily (BID). b. 9/30/17, [MEDICATION NAME] 5 mg every six hours; at 2:00 AM, 8:00 AM, 2:00 PM and 8:00 PM, Hold if asleep. c. 8/15/17, [MEDICATION NAME] 20 mg QHS (bedtime) hold for systolic (blood pressure (BP)) The MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following: a. [MEDICATION NAME] 0.5 mg administered on 1/27/18 at 10:00 PM, 2/22/18 at 12:00 PM, 3/12/18 at 11:00 PM and 3/27/18 at 10:00 PM. Administration of the [MEDICATION NAME] 0.5 mg were administered two to four hours after they were due. b. [MEDICATION NAME] 0.5 mg was not administered on 2/28/18. c. [MEDICATION NAME] 5 mg administered on 3/24/18 at 10:00 PM, 4/7/18 at 12:00 AM, 4/10/18 at 9:30 AM and 4/23/18 at 4:45 AM. Three administrations of the [MEDICATION NAME] 5 mg were administered 1 1/2 hours to 2 hours and 45 minutes after they were due. The administration of the [MEDICATION NAME] 5 mg at 12:00 AM was administered 2 hours before it was due. d. [MEDICATION NAME] 5 mg was not administered on 1/12/18 at 2:00 PM, 1/14/18 at 8:00 PM, 1/16/18 at 2:00 PM, 2/22/18 at 8:00 AM, 2/22/18 at 2:00 PM, 3/8/18 at 8:00 AM, 4/10/18 at 2:00 PM. d. [MEDICATION NAME] 20 mg was administered on 1/11/18 with a BP of 108/70, 1/18/18 with a BP 112/57, 1/19/18 with a BP 132/56, 2/24/18 with a BP 109/56, 3/22/18 with a BP 120/51, 3/25/18 with a BP 112/58. 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. 10/30/17 through 11/9/17,[MEDICATION NAME] mg twice daily at 8:00 AM and 8:00 PM for UTI. b. 12/20/17 through 12/24/17, [MEDICATION NAME] 1.25 grams IV daily at 5:00 PM [MEDICAL CONDITION] Bacteremia. c. 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: a.[MEDICATION NAME] mg administered on 11/2/17 at 10:24 AM, 11/3/17 at 9:27 AM and 11/7/17 at 10:20 PM. Administration of [MEDICATION NAME] mg was 1 hour and 27 minutes to 2 hours and 24 minutes after they were due. b. [MEDICATION NAME] 1.25 grams IV administered on 12/20/17 at 7:23 PM. Administration of the [MEDICATION NAME] 1.25 grams was 2 hours and 23 minutes after it was due. c. Eliquis 5 mg not administered on 11/24/17 at 8:00 AM because med not avaialble(sic) notifeid (sic) pharmacy. 4. Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 169's medical record was reviewed. A Medication Error report form dated 4/12/18, revealed that resident 169 had a [MEDICATION NAME] 7.5/325 mg tablet administered rather than the [MEDICATION NAME] 7.5/325 mg tablet as ordered by her physician. 5. Resident 168 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 168's medical record was reviewed. A Medication Error report form dated 2/14/18 revealed that resident 168 was to receive [MEDICATION NAME] 7.5 mg daily at bedtime. The physician's orders [REDACTED]. 6. Resident 166 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 166's medical record was reviewed. A Medication Error report form dated 12/7/17 revealed that resident 166 had to receive D ([MEDICATION NAME]) 5W at 75 ml/hr, [MEDICATION NAME] as needed and blood sugar checks every 30 minutes due to a second administration of resident 166's [MEDICATION NAME] 30 units after the nurse misread the MAR. A Medication Error report form dated 2/23/18 revealed that resident 166 was to receive Losartan 50 mg daily. The physician's orders [REDACTED]. 7. Resident 20 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 20's medical record was reviewed. A Medication Error report form dated 2/14/18 revealed that resident 20 had not received his [MEDICATION NAME] Patch on 12/11/18. 8. 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. A Medication Error report form dated 12/17/18 revealed that resident 165 had [MEDICATION NAME] administered rather than the [MEDICATION NAME] for his pain on 12/16/18. 9. 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 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. 10. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 25's medical record was reviewed. physician's orders [REDACTED]. a. 12/5/17, [MEDICATION NAME] 0.5 mg BID. b. 2/23/18, [MEDICATION NAME] 0.5 mg BID. The MAR for (MONTH) (YEAR) and (MONTH) (YEAR) for resident 25 revealed the following: a. [MEDICATION NAME] 0.5 mg was administered late on 3/1/18, 3/2/18, 3/3/18, 3/5/18, 3/6/18, 3/7/18, 3/8/18, 3/9/18, 3/12/18, 3/14/18, 3/16/18, 3/17/18, 3/18/18, 3/19/18, 3/22/18, 3/27/18, 3/29/18, 4/4/18, 4/12/18, 4/17/18, 4/20/18, 4/23/18 and 4/24/18. b. [MEDICATION NAME] 0.5 mg, was administered late on 3/6/18, 3/19/18, 3/27/18, 4/4/18, 4/12/18, 4/17/18, 4/20/18, 4/23/18, and 4/24/18. 11. Resident 45 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18, resident 45's medical record was reviewed. physician's orders [REDACTED]. a. Humalog sliding scale insulin before meals and at HS. b. [MEDICATION NAME] 50 units BID. The MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) for resident 45 revealed the following: a. Humalog sliding scale insulin was administered late on 1/2/18, 1/3/18, 1/4/18, 1/8/18, 1/9/18, 1/10/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/15/18, 1/16/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, 1/25/18, 1/26/18, 1/27/18, 1/28/18, 1/29/18, 2/2/18, 2/5/18, 2/6/18, 2/7/18, 2/9/18, 2/10/18, 2/12/18, 2/16/18, 2/17/18, 2/21/18, 2/22/18, 2/23/18, 2/25/18, 2/26/18, 2/27/18, 2/28/18, 3/5/18, 3/9/18, 3/10/18, 3/12/18, 3/17/18, 3/18/18, 3/19/18, 3/20/18, 3/21/18, 3/22/18, 3/23/18, 3/25/18, 3/26/18, 3/29/18, 3/30/18, 3/31/18, 4/1/18, 4/3/18, 4/6/18, 4/9/18, 4/10/18, 4/12/18, 4/19/18, and 4/20/18. b. [MEDICATION NAME] Insulin was administered late on 1/2/18, 1/4/18, 1/8/18, 1/9/18, 1/10/18, 1/11/18, 1/13/18, 1/14/18, 1/15/18, 1/16/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, 1/25/18, 1/26/18, 1/28/18, 1/29/18, 2/2/18, 2/5/18, 2/7/18, 2/9/18, 2/18/18, 2/21/18, 2/22/18, 2/23/18, 2/25/18, 2/28/18, 3/4/18, 3/5/18, 3/9/18, 3/12/18, 3/17/18, 3/18/18, 3/19/18, 3/21/18, 3/22/18, 3/23/18, 3/25/18, 3/26/18, 3/29/18, 3/30/18, 3/31/18, 4/1/18, 4/6/18, 4/9/18, 4/10/18, 4/12/1/18, and 4/20/18. 12. Resident 59 resident was originally admitted on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. substance dependence. On 4/30/18 resident 59's medical record was reviewed. physician's orders [REDACTED]. a. [MEDICATION NAME] 55 units QHS. b. [MEDICATION NAME] Insulin 15 units TID. c. [MEDICATION NAME] 2 grams/100 ml Q 8 hours. The MAR for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) for resident 59 revealed the following: a. [MEDICATION NAME] was administered late on 1/29/18, 1/30/18,1/3/18, 2/9/18,2/11/18, 2/14/18 and 4/17/18. b. [MEDICATION NAME] Insulin was administered late on 1/29/18, 2/1/18, 2/2/18, 2/5/18, 2/8/18, 2/9/18, 2/15/18, 2/16/18, 2/20/18, 2/22/18. c. [MEDICATION NAME] was administered late on 2/1/18 X 2, 2/2/18, 2/5/18, 2/8/18, 2/9/18 x 2, 2/10/18, 2/11/18, 2/12/18, 2/15/18, 2/16/18, 2/17/18, 2/18/18, 2/19/18 x 2, 2/21/18 x 2, 2/22/18 x 2, and 2/23/18. 13. Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/18 resident 30's medical record was reviewed. physician's orders [REDACTED]. a. [MEDICATION NAME] 30 mg TID. Hold for SBP b. Carvedilol 25 mg BID. Hold for SBP c. [MEDICATION NAME] 10 mg QD. Hold for SBP A Medication Error report form for revealed that resident 30 had 52 medication administration error's for (MONTH) (YEAR). A Medication Error report form revealed that resident 30 had 151 medication administration error's for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR). Each of the medication administration error's was due to administration of the [MEDICATION NAME], Carvedilol, or [MEDICATION NAME] outside of the parameters set by the physician. The MAR for February, (MONTH) and (MONTH) (YEAR) revealed the following errors: [MEDICATION NAME]: a) 2/1/2018 at 8:00 AM diastolic blood pressure (BP) was measured at 70 b) 2/2/2018 at 8:00 AM diastolic BP was measured at 77 c) 2/6/2018 at 8:00 AM diastolic BP was measured at 68 d) 2/8/2018 at 8:00 AM diastolic BP was measured at 78 e) 2/11/2018 at 8:00 AM diastolic BP was measured at 79 f) 2/16/2018 at 8:00 AM diastolic BP was measured at 78 g) 2/17/2018 at 8:00 AM diastolic BP was measured at 78 h) 2/20/2018 at 8:00 AM diastolic BP was measured at 77 i) 2/21/18 at 8:00 AM BP was measured at 133 systolic and 78 diastolic j) 2/22/2018 at 8:00 AM diastolic BP was measured at 74 k) 2/23/2018 at 8:00 AM diastolic BP was measured at 65 l) 2/24/2018 at 8:00 AM diastolic BP was measured at 72 m) 3/11/2018 at 8:00 AM diastolic BP was measured at 74 n) 3/14/2018 at 8:00 AM diastolic BP was measured at 69 o) 3/15/2018 at 8:00 AM diastolic BP was measured at 73 p) 3/17/2018 at 8:00 AM diastolic BP was measured at 72 q) 3/20/2018 at 8:00 AM diastolic BP was measured at 78 r) 3/24/2018 at 8:00 AM BP was measured at 127 systolic and 60 diastolic s) 3/29/2018 at 8:00 AM diastolic BP was measured at 63 t) 3/30/2018 at 8:00 AM BP was measured at 113 systolic and 56 diastolic u) 3/31/2018 at 8:00 AM diastolic BP was measured at 68 v) On 4/5/18 at 8:00 AM, diastolic BP was measured at 75 w) On 4/6/18 at 8:00 AM, diastolic BP was measured at 75 x) On 4/7/18 at 8:00 AM, BP was measured at 127 systolic and 60 diastolic y) On 4/12/18 at 8:00 AM, diastolic BP was measured at 65 z) On 4/13/18 at 8:00 AM, diastolic BP was measured at 72 aa) On 4/14/18 at 8:00 AM, diastolic BP was measured at 72 bb) On 4/17/18 at 8:00 AM, diastolic BP was measured at 70 cc) On 4/19/18 at 8:00 AM, diastolic BP was measured at 68 dd) On 4/20/18 at 8:00 AM, diastolic BP was measured at 70 ee) On 4/20/18 at 8:00 AM, diastolic BP was measured at 71 ff) On 4/24/18 at 8:00 AM, diastolic BP was measured at 70 Carvedilol: a) 2/1/2018 at 8:00 AM diastolic BP was measured at 70 b) 2/2/2018 at 8:00 AM diastolic BP was measured at 77 c) 2/2/2018 at 8:00 PM BP was measured at 135 systolic and 74 diastolic d) 2/6/2018 at 8:00 AM diastolic BP was measured at 68 e) 2/8/2018 at 8:00 AM diastolic BP was measured at 78 f) 2/9/2018 at 8:00 PM diastolic BP was measured at 78 g) 2/11/2018 at 8:00 AM diastolic BP was measured at 79 h) 2/11/2018 at 8:00 PM diastolic BP was measured at 79 i) 2/16/2018 at 8:00 AM diastolic BP was measured at 78 j) 2/17/2018 at 8:00 AM diastolic BP was measured at 78 k) 2/20/2018 at 8:00 AM diastolic BP was measured at 77 l) 2/21/18 at 8:00 AM BP was measured at 133 systolic and 78 diastolic m) 2/21/2018 at 8:00 PM diastolic BP was measured at 78 n) 2/22/2018 at 8:00 AM diastolic BP was measured at 74 o) 2/22/2018 at 8:00 PM diastolic BP was measured at 78 p) 2/23/2018 at 8:00 AM diastolic BP was measured at 65 q) 2/24/2018 at 8:00 AM diastolic BP was measured at 72 r) 2/24/2018 at 8:00 PM diastolic BP was measured at 78 s) 3/1/2018 at 8:00 PM BP was measured at 122 systolic and 68 diastolic t) 3/2/2018 at 8:00 PM BP was measured at 128 systolic and 76 diastolic u) 3/7/2018 at 8:00 PM BP was measured at 138 systolic and 78 diastolic v) 3/8/2018 at 8:00 PM diastolic BP was measured at 72 w) 3/9/2018 at 8:00 AM diastolic BP was measured at 72 x) 3/10/2018 at 8:00 PM diastolic BP was measured at 74 y) 3/11/2018 at 8:00 AM diastolic BP was measured at 74 z) 3/12/2018 at 8:00 PM BP was measured at 128 systolic and 68 diastolic aa) 3/14/2018 at 8:00 AM diastolic BP was measured at 69 bb) 3/14/2018 at 8:00 PM diastolic BP was measured at 69 cc) 3/15/2018 at 8:00 AM diastolic BP was measured at 73 dd) 3/15/2018 at 8:00 PM diastolic BP was measured at 76 ee) 3/17/2018 at 8:00 AM diastolic BP was measured at 72 ff) 3/20/2018 at 8:00 AM diastolic BP was measured at 78 gg) 3/20/2018 at 8:00 PM diastolic BP was measured at 72 hh) 3/24/2018 at 8:00 AM BP was measured at 127 systolic and 60 diastolic ii) 3/26/2018 at 8:00 PM diastolic BP was measured at 75 jj) 3/28/2018 at 8:00 PM diastolic BP was measured at 78 kk) 3/29/2018 at 8:00 AM diastolic BP was measured at 63 ll) 3/29/2018 at 8:00 PM BP was measured at 136 systolic and 74 diastolic mm) 3/30/2018 at 8:00 AM BP was measured at 113 systolic and 56 diastolic nn) 3/31/2018 at 8:00 AM diastolic BP was measured at 68 oo) On 4/5/18 at 8:00 AM diastolic BP was measured at 75 pp) On 4/5/18 at 8:00 PM diastolic BP was measured at 78 qq) On 4/6/18 at 8:00 AM diastolic BP was measured at 75 rr) On 4/7/18 at 8:00 AM BP was measured at 127 systolic and 60 diastolic ss) On 4/12/18 at 8:00 AM diastolic BP was measured at 65 tt) On 4/13/18 at 8:00 AM diastolic BP was measured at 72 uu) On 4/14/18 at 8:00 AM diastolic BP was measured at 72 vv) On 4/17/18 at 8:00 AM diastolic BP was measured at 70 ww) On 4/19/18 at 8:00 AM diastolic BP was measured at 68 xx) On 4/20/18 at 8:00 AM diastolic BP was measured at 70 yy) On 4/21/18 at 8:00 AM diastolic BP was measured at 71 zz) On 4/24/18 at 8:00 AM diastolic BP was measured at 70 aaa) On 4/7/18 at 8:00 PM diastolic BP was measured at 79 bbb) On 4/8/18 at 8:00 PM systolic BP was measured at 136 ccc) On 4/12/18 at 8:00 PM diastolic BP was measured at 78 ddd) On 4/14/18 at 8:00 PM diastolic BP was measured at 78 [MEDICATION NAME]: a) 2/1/2018 at 8:00 AM diastolic BP was measured at 70 b) 2/2/2018 at 8:00 AM diastolic BP was measured at 77 c) 2/2/2018 at 8:00 PM BP was measured at 135 systolic and 74 diastolic d) 2/3/2018 at 3:00 PM diastolic was measured at 77 e) 2/6/2018 at 8:00 AM diastolic BP was measured at 68 f) 2/8/2018 at 8:00 AM diastolic BP was measured at 78 g) 2/9/2018 at 9:00 PM diastolic BP was measured at 78 h) 2/11/2018 at 8:00 AM diastolic BP was measured at 79 i) 2/11/2018 at 8:00 PM diastolic BP was measured at 79 j) 2/16/2018 at 8:00 AM diastolic BP was measured at 78 k) 2/16/2018 at 9:00 PM diastolic BP was measured at 78 l) 2/17/2018 at 8:00 AM diastolic BP was measured at 78 m) 2/17/2018 at 3:00 PM diastolic BP was measured at 78 n) 2/20/2018 at 8:00 AM diastolic BP was measured at 77 o) 2/21/2018 at 8:00 AM BP was measured at 133 systolic and 78 diastolic p) 2/21/2018 at 3:00 PM diastolic BP was measured at 78 q) 2/21/2018 at 9:00 PM diastolic BP was measured at 78 r) 2/22/2018 at 8:00 AM diastolic BP was measured at 74 s) 2/22/2018 at 3:00 PM diastolic BP was measured at 76 t) 2/22/2018 at 9:00 PM diastolic BP was measured at 78 u) 2/23/2018 at 8:00 AM diastolic BP was measured at 65 v) 2/23/2018 at 3:00 PM diastolic BP was measured at 72 w) 2/24/2018 at 8:00 AM diastolic BP was measured at 72 x) 2/24/2018 at 9:00 PM diastolic BP was measured at 78 y) 2/28/2018 at 3:00 PM BP was measured at 130 systolic and 70 diastolic z) 3/1/2018 at 9:00 PM BP was measured at 122 systolic and 68 diastolic aa) 3/2/2018 at 9:00 PM BP was measured at 128 systolic and 76 diastolic bb) 3/7/2018 at 9:00 PM BP was measured at 138 systolic and 78 diastolic cc) 3/10/2018 at 9:00 PM diastolic BP was measured at 74 dd) 3/11/2018 at 8:00 AM diastolic BP was measured at 74 ee) 3/12/2018 at 9:00 PM BP was measured at 138 systolic and 72 diastolic ff) 3/14/2018 at 8:00 AM diastolic BP was measured at 69 gg) 3/14/2018 at 9:00 PM diastolic BP was measured at 69 hh) 3/15/2018 at 8:00 AM diastolic BP was measured at 73 ii) 3/15/2018 at 8:00 PM diastolic BP was measured at 76 jj) 3/17/2018 at 8:00 AM diastolic BP was measured at 72 kk) 3/20/2018 at 8:00 AM diastolic BP was measured at 78 ll) 3/20/2018 at 8:00 PM diastolic BP was measured at 72 mm) 3/24/2018 at 8:00 AM BP was measured at 127 systolic and 60 diastolic nn) 3/26/2018 at 8:00 PM diastolic BP was measured at 75 oo) 3/28/2018 at 8:00 PM diastolic BP was measured at 78 pp) 3/29/2018 at 8:00 AM diastolic BP was measured at 63 qq) 3/29/2018 at 8:00 PM BP was measured at 136 systolic and 74 diastolic rr) 3/30/2018 at 8:00 AM BP was measured at 113 systolic and 56 diastolic ss) 3/31/2018 at 8:00 AM diastolic BP was measured at 68 tt) On 4/5/18 at 8:00 AM diastolic BP was measured at 75 uu) On 4/5/18 at 9:00 PM diastolic BP was measured at 78 vv) On 4/6/18 at 8:00 AM diastolic BP was measured at 65 ww) On 4/7/18 at 8:00 AM BP was measured at 127 systolic and 60 diastolic xx) On 4/7/18 at 9:00 PM diastolic BP was measured at 79 yy) On 4/8/18 at 9:00 PM systolic BP was measured at 136 zz) On 4/11/18 at 3:00 PM diastolic BP was measured at 69 aaa) On 4/12/18 at 8:00 AM diastolic BP was measured at 65 bbb) On 4/12/18 at 9:00 PM diastolic BP was measured at 78 ccc) On 4/13/18 at 8:00 AM diastolic BP was measured at 65 ddd) On 4/14/18 at 8:00 AM diastolic BP was measured at 72 eee) On 4/14/18 at 9:00 PM diastolic BP was measured at 78 fff) On 4/17/18 at 3:00 PM diastolic BP was measured at 70 ggg) On 4/19/18 at 8:00 AM diastolic BP was measured at 68 hhh) On 4/20/18 at 8:00 AM diastolic BP was measured at 70 iii) On 4/21/18 at 8:00 AM diastolic BP was measured at 71 jjj) On 4/22/18 at 3:00 PM diastolic BP was measured at 79 kkk) On 4/25/18 at 3:00 PM BP was measured at 137 systolic and 86 diastolic On 4/30/18 an interview was conducted with the facility DON. The facility DON stated that she was aware that the resident had many medication errors in January. When the errors in February, March, and (MONTH) were revealed, the DON acknowledged that they should not have happened. In addition, resident 30 had physician's orders [REDACTED]. a) [MEDICATION NAME], 10 milligrams (mg), 1 time per day b) Carvedilol, 25 mg, 2 times per day. (Note: This order was changed on 4/6/18 to 25 mg once in the morning and 37.5 mg once an evening.) c) [MEDICATION NAME], 30 mg, 3 times per day d) [MEDICATION NAME], 100 unit/mL, 8 units, at bedtime e) [MEDICATION NAME], 5 mg, once a day f) [MEDICATION NAME] 100 unit/mL, administer per sliding scale, before meals g) [MEDICATION NAME], 40 mg, once a day Resident 30's MAR indicated [REDACTED] a) [MEDICATION NAME], had no blood pressure measurement or administration information on 2/27/18. was administered late on 1/5/18, 1/13/18, 1/14/18, 1/18/18, 1/19/18, 1/21/18, 1/26/18, 1/29/18, 2/1/18, 2/3/18, 2/6/18, 2/8/18, 2/10/18, 2/11/18, 2/14/18, 2/16/18, 2/17/18, 2/20/18, 2/21/18, 2/24/18, 3/1/18, 3/4/18, 3/7/18, 3/11/18, 3/13/18, 3/26/18, 3/27/18, 3/29/18, 4/7/18, 4/9/18, 4/14/18, 4/20/18 b) Carvedilol, had no blood pressure measurement or administration information on 3/11/18 at 8:00 PM or 3/27/18 at 8:00 PM. The carvedilol was administered late on 1/1/18, 1/5/18, 1/6/18, 1/7/18, 1/8/18, 1/9/18, 1/11/18, 1/12/18, 1/13/18, 1/14/18, 1/18/18, 1/19/18, 1/21/18, 1/26/18, 1/27/18, 2/1/18, 2/2/18, 2/3/18, 2/5/18, 2/6/18, 2/8/18, 2/10/18, 2/11/18 at 8:00 AM and 8:00 PM, 2/12/18 at 8:00 AM and 8:00 PM, 2/13/18 at 8:00 AM and 8:00 PM, 2/14/18, 2/16/18, 2/17/18, 2/18/18, 2/20/18, 2/21/18, 2/22/18, 2/24/18, 2/25/18, 2/28/18, 3/4/18 at 8:00 AM and 8:00 PM, 3/5/18, 3/6/18, 3/7/18 at 8:00 AM and 8:00 PM, 3/8/18, 3/9/18, 3/10/18, 3/11/18, 3/13/18 at 8:00 AM and 8:00 PM, 3/14/18, 3/15/18, 3/17/18, 3/18/18, 3/19/18, 3/23/18, 3/25/18, 3/26/18 at 8:00 AM and 8:00 PM, 3/17/18, 3/29/18, 4/1/18, 4/6/18, 4/7/18, 4/9/18, 4/12/18, 4/14/18, 4/20/18, 4/21/18 c) [MEDICATION NAME], was administered late on 1/4/18, 1/5/18, 1/7/18, 1/8/18, 1/9/18, 1/10/18, 1/13/18, 1/14/18 at 8:00 AM and 9:00 PM, 1/15/18, 1/17/18, 1/18/18, 1/19/18, 1/21/18, 1/22/18, 1/24/18 at 3:00 PM and 9:00 PM, 1/25/18, 1/26/18 8:00 AM and 9:00 PM, 1/27/18, 1/29/18 8:00 AM and 3:00 PM, 1/31/18, 2/1/18 at 8:00 AM and 3:00 PM, 2/3/18 at 8:00 AM and 3:00 PM, 2/4/18, 2/5/18 at 3:00 PM and 9:00 PM, 2/6/18, 2/8/18, 2/9/18, 2/10/18 at 8:00 AM and 3:00 PM, 2/11/18 at 8:00 AM and 9:00 PM, 2/14/18, 2/15/18, 2/16/18 at 8:00 AM and 9:00 PM, 2/17/18, 2/18/18 3:00 PM and 9:00 PM, 2/20/18, 2/21/18, 2/22/18 at 3:00 PM and 9:00 PM, 2/23/18, 2/24/18, 2/27/18 3:00 PM and 9:00 PM, 2/28/18, 3/1/18, 3/3/18, 3/4/18 at 8:00 AM, 3:00 PM and 9:00 PM, 3/5/18 at 3:00 PM and 9:00 PM, 3/6/18, 3/7/18, 3/9/18, 3/11/18 at 8:00 AM and 3:00 PM, 3/12/18, 3/13/18 at 8:00 AM and 9:00 PM, 3/15/18, 3/16/18, 3/17/18, 3/18/18, 3/19/18, 3/23/18, 3/24/18, 3/26/18 at 8:00 AM and 9:00 PM, 3/27/18 at 8:00 AM, 3:00 PM and 9:00 PM, 3/29/18, 3/31/18, 4/4/18, 4/6/18 3:00 PM and 9:00 PM, 4/7/18, 4/9/18, 4/12/18 3:00 PM and 9:00 PM, 4/13/18, 4/14/18 8:00 AM, 4/18/18, 4/20/18 d) [MEDICATION NAME], had no blood sugar measurement or administration information on 3/8/18, 3/11/18, 3/26/18, 3/27/18. The [MEDICATION NAME] was administered late on 1/2/18, 1/4/18, 1/8/18, 1/9/18, 1/10/18, 1/11/18, 1/14/18, 1/15/18, 1/16/18, 1/17/18, 1/19/18, 1/20/18, 1/25/18, 1/26/18, 1/27/18, 2/2/18, 2/5/18, 2/6/18, 2/9/18, 2/11/18, 2/12/18, 2/13/18, 2/17/18, 2/18/18, 2/19/18, 2/22/18, 2/25/18, 2/27/18, 2/28/18, 3/4/18, 3/5/18, 3/6/18, 3/9/18, 3/10/18, 3/13/18, 3/14/18, 3/17/18, 3/18/18, 3/19/18, 3/21/18, 3/23/18, 3/25/18, 4/4/18, 4/6/18, 4/9/18, 4/12/18, 4/16/18, 4/18/18, 4/19/18, 4/21/18, 4/24/18, e) [MEDICATION NAME], was administered late on 1/2/18, and 1/31/18, 2/10/18, 2/12/18, 2/13/18, 3/5/18, 3/19/18, 3/25/18, 4/2/18, 4/3/18, 4/8/18, 4/10/18, 4/11/18, 4/17/18, 4/18/18, f) [MEDICATION NAME] Insulin, had no blood sugar or administration information on 2/12/18 at 8:00 am, 2/27/18 at 12:00 PM, 3/5/18 at 8:00 AM and 12:00 PM. The [MEDICATION NAME] Insulin was administered late on 2/1/18, 2/3/18 at 8:00 AM and 5:00 PM, 2/5/18 at 12:00 PM and 5:00 PM, 2/6/18, 2/7/18, 2/8/18, 2/9/18 2/10/18, 2/12/18, 2/17/18, 2/18/18, 2/21/18, 2/25/18, 2/27/18, 2/28/18, 3/4/18, 3/5/18, 3/7/18, 3/9/18, 3/10/18, 3/11/18 at 12:00 PM and 5:00 PM, 3/12/18, 3/15/18, 3/17/18, 3/18/18 at 12:00 PM and 5:00 PM, 3/24/18, 3/25/18, 3/26/18, 3/30/18, 4/2/18, 4/5/18 at 8:00 AM and 12:00 PM, 4/6/18, 4/7/18, 4/9/18, 4/10/18 8:00 AM and 5:00 PM, 4/11/18 8:00 AM and 5:00 PM, 4/13/18, 4/15/18, 4/16/18 at 8:00 AM and 5:00 PM, 4/17/18, 4/18/18, g) [MEDICATION NAME], was administered late on 1/4/18, 1/5/18, 1/6/18, 1/7/18, 1/11/18, 1/12/18, 1/13/18, 1/15/18, 1/18/18, 1/19/18, 1/20/18, 1/22/19, 1/23/18, 1/24/18, 1/26/18, 1/28/18, 2/1/18, 2/3/18, 2/4/18, 2/5/18, 2/6/18, 2/7/18, 2/8/18, 2/10/18, 2/11/18, 2/12/18, 2/13/18, 2/14/18, 2/16/18, 2/17/18, 2/19/18, 2/20/18, 2/21/18, 2/24/18, 2/26/18, 3/2/18, 3/3/18, 3/4/18, 3/5/18, 3/6/18, 3/7/18, 3/8/18, 3/11/18 at 8:00 AM and 12:00 PM, 3/13/18, 3/22/18, 3/26/18, 3/27/18, 3/29/18, 4/2/18, 4/4/18, 4/7/18, 4/11/18, 4/13/18, 4/14/18, 4/20/18 14. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 18 had physician orders [REDACTED]. a) [MEDICATION NAME], 100 mcg/hr, once a day every 3 days b) [MEDICATION NAME], 15 mg, four times a day Resident 18's MAR indicated [REDACTED] |
2020-09-01 |