cms_VT: 748
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
748 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2016-09-13 | 281 | G | 1 | 0 | 0MLI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to ensure that nurses met professional standards of nursing practice regarding failure to follow physician orders [REDACTED].#2) Findings include: 1. Per record review, due to a transcription error, Resident #2 was not administered physician ordered [MEDICATION NAME] for 5 days and experienced physical symptoms of increased [MEDICAL CONDITION], weight gain, shortness of breath and lethargy that impacted his/her health and safety ([MEDICATION NAME] is a diuretic medication that helps the body get rid of excess fluid). Resident #2 had [DIAGNOSES REDACTED]. On 8/18/16 the Resident's physician ordered an increase in [MEDICATION NAME] from 40 mg daily to 40 mg twice daily for 5 days and then was to resume [MEDICATION NAME] 40 mg daily. Per review of the MAR (Medication Administration Record), the resident received the increased dose of [MEDICATION NAME] from 8/18/16 -8/22/16. On 8/23/16 the resident received 1 dose of [MEDICATION NAME] 40 mg and then did not receive the medication from 8/24-8/28/16 (5 days) until the error was discovered on 8/29/16. Per interview on 9/13/16 beginning at approximately 9:00 AM, the nursing UM (Unit Manager) stated that there was a transcription error made in the MAR indicated [REDACTED]. S/he confirmed during the interview that the physician orders [REDACTED]. 2. Per record review, Resident #2 did not receive his/her physician ordered IV (intravenous) infusions of [MEDICATION NAME]/Sulbactam (antibiotic) to treat osteo[DIAGNOSES REDACTED] (infection into the bone of the left foot) as ordered. Per record review, Resident #2 was admitted to the facility for IV antibiotic treatment of [REDACTED]. The orders stated to give [MEDICATION NAME]/Sulbactam 3 gm every 8 hours IV through a PICC line (peripherally inserted central catheter). Per review of the infusion Medication Administration Record [REDACTED]. Per interview with the UM (Unit Manager) on 9/13/16 at approximately 9:00 AM, s/he reported that on some of the days, the resident had medical appointments and left the facility at about 5- 5:30 AM and returned at about 6:00 PM; the UM also reported that on some of the other days, s/he thought there could be a documentation error and thinks the resident could have been administered the antibiotic. The UM confirmed that the prescribing physician was not contacted to see if the antibiotic could be held for medical appointments or administered on a different time schedule or given at the medical appointment for the days that the antibiotic was not administered due to medical appointments. 3. Per record review, nursing staff failed to obtain new orders for wound care for Resident #2 after the 8/23/16 order for wound cleansing and wet to dry dressings ended on 8/29/16. Per record review, there was no evidence that the wound had healed as a nursing skin assessment on 9/1/16 documented that the resident had a wound on the bottom of the left foot. A discharge summary by the facility nurse practitioner dated 9/2/16 documented that the resident had a small residual wound on the plantar aspect of the left foot. On 9/13/16 at an interview beginning at approximately 9:00 AM, the Unit Manager (UM) confirmed that nursing staff had not obtained an order for [REDACTED]. Additionally, the UM confirmed that there was no evidence that the wound was assessed or measured after 8/22/16 and that an assessment and measurement should have been obtained weekly per policy (the resident was discharged from the facility on 9/6/16). (Refer to F 282, 333, 514) | 2019-09-01 |