cms_UT: 76
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 76 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2019-11-06 | 760 | D | 0 | 1 | F3KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility did not ensure the residents were free of significant medication errors. Specifically, the facility did not administer [MEDICATION NAME] as ordered by the physician and the [MEDICATION NAME] order was not discontinued timely. Resident identifier: 2. Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 11/5/19. 1. The Discharge Instructions/Order from the local hospital dated 7/19/19, documented that resident 2 had [DIAGNOSES REDACTED]. Resident 2 had a long term current use of anticoagulants related to [DIAGNOSES REDACTED] complicated by multiple [MEDICAL CONDITION] and ischemic [MEDICAL CONDITION]. Goal international normalized ratio (INR) was to be between 2 to 3. The hospital recommended continuing the [MEDICATION NAME] at 10 milligrams (mg) daily supplemented by [MEDICATION NAME] until INR in goal range. A review of the facility Order Summary Report documented the following physician's orders [REDACTED]. Continue until INR greater than (>) 2.0. A review of the PT ([MEDICATION NAME] time)/INR Dipstick Test documented that resident 2 had an INR of 2.7 on 7/22/19. Current Meds (Medications): [MEDICATION NAME] 7.5 mg and [MEDICATION NAME] discontinue when > 2.0. The Nurse Practitioner (NP) noted no change and check INR in one week on 7/29/19. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 3.6 on 7/29/19. Current Meds: [MEDICATION NAME] 7.5 mg daily and [MEDICATION NAME] discontinue when > 2.0. The NP noted to hold times 1 dose and check INR tomorrow on 7/30/19. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 2.7 on 7/30/19. Current Meds: [MEDICATION NAME] 7.5 mg held on 7/29/19. [MEDICATION NAME] 120 mg/0.8 ml continue until INR > 2.0. The NP noted to discontinue the [MEDICATION NAME] and check INR in 3 days. A review of the (MONTH) 2019 Medication Administration Record (MAR) documented that the [MEDICATION NAME] was discontinued on 7/30/19 at 5:48 PM. (Note: Resident 2 had an INR of 2.7 on 7/22/19. Resident 2 received 16 additional doses of [MEDICATION NAME].) 2. A review of the facility Order Summary Report documented the following physician's orders [REDACTED]. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 3.6 on 7/29/19. Current Meds: [MEDICATION NAME] 7.5 mg daily and [MEDICATION NAME] discontinue when > 2.0. The NP noted to hold times 1 dose and check INR tomorrow on 7/30/19. A review of the (MONTH) 2019 MAR documented that [MEDICATION NAME] 7.5 mg was administered on 7/29/19. The [MEDICATION NAME] dose should have been held. A review of the Patient [MEDICATION NAME] Log documented that resident 2 had an INR of 3.2 on 8/2/19. [MEDICATION NAME] Dose 7.5 mg. New Orders 7.5 mg on Saturday, Sunday, Tuesday, Thursday and 7 mg on Monday, Wednesday, and Friday. Next Test Date 8/5/19. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 2.4 on 8/5/19. Current Meds: [MEDICATION NAME] 7.5 mg on Saturday, Sunday, Tuesday, Thursday and 7 mg on Monday, Wednesday, and Friday. The NP noted no change and check INR in 1 week on 8/12/19. A review of the (MONTH) 2019 MAR documented that [MEDICATION NAME] 7.5 mg was administered on Monday 8/5/19. Resident 2 should have received 7 mg of [MEDICATION NAME]. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 2.6 on 9/5/19. Current Meds: [MEDICATION NAME] 9 mg. The Physician's Assistant was notified. No change and check INR in 1 week on 9/12/19. A review of the (MONTH) 2019 MAR documented that resident 2 had not received any [MEDICATION NAME] on 9/5/19, 9/6/19, 9/7/19, 9/8/19, 9/9/19, 9/10/19. and 9/11/19. A Nursing Progress Note dated 9/12/19, documented It was discovered that resident has not had [MEDICATION NAME] for the past week. INR today was taken and was 1.1. MD (Medical Director) was notified. Order to resume dose of 9 mg. Will continue to monitor patient. On 11/6/19 at 10:04 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident INR checks were documented on the Patient [MEDICATION NAME] log. LPN 1 stated that when an INR was due she would complete an INR worksheet. LPN 1 stated that the NP or MD would review the resident medical record and would make recommendations on the [MEDICATION NAME] dose and when to check the next INR. LPN 1 stated that after the INR worksheet was reviewed by the NP or MD the results and recommendations were recorded on the Patient [MEDICATION NAME] Log. LPN 1 further stated that the nursing staff would input the orders onto the resident MAR and the Director of Nursing (DON) would double check the orders for accuracy. LPN 1 stated that the facility had an INR machine and the nursing staff were able to complete the INR checks in the facility. LPN 1 stated that resident 2's surgeon or MD would have been contacted when resident 2 was therapeutic with the INR checks. LPN 1 stated that resident 2's surgeon or MD would have been contacted to have the [MEDICATION NAME] discontinued. LPN 1 further stated that she would contact the surgeon or MD if a resident was unable to tolerate the medication injections. LPN 1 stated that she would not discontinue a medication without contacting the MD. LPN 1 stated that if the MD was contacted she would document the contact either in a progress note or on the resident MAR. On 11/6/19 at 12:38 PM, an interview was conducted with the DON. The DON stated that the nursing staff were expected to verify initial orders from the hospital. The DON stated that the NP or the MD visit notes should reflect that the resident medications were reviewed. The DON stated that any orders the NP or MD put in place would supercede the hospital orders. The DON stated that the medication error for resident 2 was identified and was included in the facility Quality Assurance program on 9/13/19. The DON stated that herself or the nurse manager would track the [MEDICATION NAME] orders and the next INR check dates. The DON stated she would give the nursing staff a list for the day of the INR checks that were due. The DON stated that the INR worksheet would be completed by the nursing staff and reviewed by the clinician. The DON stated that the nursing staff would input new orders onto the resident MAR. The DON further stated that on the following morning she would verify the orders in the medical record and would document the orders on the tracking log. | 2020-09-01 |