cms_UT: 53
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 53 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 849 | D | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined for 2 of 43 sample residents that the facility did not ensure that ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. Specifically, two resident who were admitted to the facility on hospice, did not receive medications timely. Resident identifiers: 63 and 165. Findings include: 1. 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. 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]; [MEDICAL CONDITION]; DGD (diabetes and glandular disease); restless 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]. Pt 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. 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 (twice daily) 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 63 had been admitted under their care for hospice services and that resident 63 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 63 which contained [MEDICATION NAME] and [MEDICATION NAME]. 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 the hospice company was suppose to send all of resident 63's medications. 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. 2. 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 1:55 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 resident 165 should have had his medications available to him. Crosss Refer to F-684 | 2020-09-01 |