| 62 |
MT OLYMPUS REHABILITATION CENTER |
465006 |
2200 EAST 3300 SOUTH |
SALT LAKE CITY |
UT |
84109 |
2019-05-23 |
757 |
D |
0 |
1 |
PDL911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 28 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not administer blood pressure medications as ordered by the resident's physician. Resident identifiers: 16 and 39. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a medical record review was conducted for resident 16. A physician's orders [REDACTED]. A review of resident 16's Medication Administration Record [REDACTED] a. On 4/14/19, for the PM dose, BP 99/62 b. On 4/18/19, for the PM dose, BP 90/51 c. On 4/19/19, for the PM dose, BP 97/62 On 5/22/19 at 12:29 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that the MAR indicated [REDACTED]. RN 2 was able to identify that resident 16's blood pressure medication was ordered to be held if the SBP was below 110. RN 2 stated that she would have contacted the physician when the blood pressure was out of parameters and would not administer the medication. RN 2 identified that the medication should have been held for resident 16. On 5/22/19 at 12:55 PM, an interview was conducted with the Director of Nursing (DON). The DON identified that the medication for resident 16 was given outside of the physician's orders [REDACTED]. 2. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a record review was completed for resident 39. Resident 39's physician's orders [REDACTED]. a. On 3/6/19, [MEDICATION NAME] HCL ([MEDICATION NAME]) tablet, 60 mg, give 60 mg by mouth three times a day for HTN, Hold for SBP b. On 3/15/19, [MEDICATION NAME] HCL tablet, 60 mg, give 60 mg by mouth three times a day [MEDICAL CONDITION] for SBP c. On 3/21/19, [MEDICATION NAME] HCL tablet 2.5 mg, give one tablet by mouth two times a day for [MEDICAL CONDITION]. Hold if SBP > (greater than) 150. Resident 39's (MONTH) 2019 MAR indicated [REDACTED] a. On 3/6/19 at 8:00 PM, for a BP of 103/77 b. On 3/7/19 at 8:00 PM, for a BP of 107/70 c. On 3/11/19 at 8:00 PM, for a BP of 103/68 d. On 3/16/19 at 8:00 AM, for a BP of 109/73 e. On 3/16/19 at 2:00 PM, for a BP of 109/73 f. On 3/16/19 at 8:00 PM, for a BP of 99/66 g. On 3/18/19 at 8:00 PM, for a BP of 105/70 h. On 3/19/19 at 8:00 AM, for a BP of 105/70 i. On 3/19/19 at 2:00 PM, for a BP of 105/70 Resident 39's (MONTH) 2019 MAR indicated [REDACTED]. On 5/22/19 at 12:29 PM, an interview was conducted with RN 2. RN 2 stated that the physician's orders [REDACTED]. RN 2 stated that the parameters were displayed before the nurse obtained the medication. RN 2 stated that the nurse was responsible to determine if the resident should receive a particular medication based on the parameters. RN 2 stated that the medications should have been held for resident 39 and the physician should have been contacted. On 5/22/19 at 12:39 PM, an interview was conducted with RN 1. RN 1 stated that none of the providers had authorized nurses to give medications outside the ordered parameters. RN 1 stated that a nurse should have charted if the physician was contacted and an order was received to give the medication outside of the parameters established in the order. RN 1 stated that the blood pressure medication for resident 39 should have been held based on the ordered parameters. On 5/22/19 at 12:45 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the nurses were responsible to watch for the parameters of medication orders. LPN 1 stated that it was the nurse's responsibility to determine if a medication should be administered based on the order. LPN 1 stated that an order to hold blood pressure medication with an SBP under 110 was standard protocol. LPN 1 stated that if he had questions about the validity of a blood pressure reading, he would obtain the BP himself. LPN 1 stated that he carried a manual blood pressure cuff to obtain a more accurate reading. On 5/22/19 at 12:55 PM, an interview was conducted with the DON. The DON identified that the medications for resident 39 were administered outside of the physician's orders [REDACTED]. |
2020-09-01 |