cms_WV: 11424
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11424 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 309 | G | U2Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, staff interview, and review of facility records, policies, and procedures, the facility failed to provide ongoing assessment / monitoring for and failed to obtain timely medical intervention for one (1) of eleven (11) sampled residents who simultaneously received [MEDICATION NAME] (an anticoagulant) and Bactrim DS (an antibiotic that potentiates anticoagulant effects) from 10/11/10 through 10/15/10. Resident #29 was found on the floor in her room (an un-witnessed fall) on the morning of 10/14/10. The day shift nurse on 10/14/10 recorded the fall in the nursing notes, noting no injury was apparent at the time. No further entries were made in the resident's nursing notes until 3:20 p.m. on 10/15/10, when the evening shift nurse noted the presence of bruising with hematoma to the resident's left temple and noted the resident appeared to have difficulty opening her left eye. The evening shift nurse contacted the attending physician, who stated that he had not previously been informed of the resident's fall and ordered that she be sent to the hospital emergency room for evaluation, as she was on a blood thinner. The resident was transported to Hospital #1's ER, where she was noted to have critical lab values related to her anticoagulation therapy and subarachnoid bleeding. The resident was later transferred to Hospital #2, where she was admitted to its neurology intensive care unit. According to the Hospital #2 discharge summary, Resident #29's subarachnoid hemorrhaging was "secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..." Nursing assistants on the early afternoon of 10/14/10 and the morning of 10/15/10 reported to the licensed nursing staff that Resident #29 had a bruise to her left temple, but no on-going neurologic assessments were completed by the licensed nursing staff after the initial assessment occurred shortly after the fall on the morning of 10/14/10, the physician was not notified of the fall or subsequent bruising to the resident's temple until the afternoon of 10/15/10, and no one at the facility recognized and/or was monitoring the resident for increased anticoagulant effects associated with administering Bactrim DS with [MEDICATION NAME]. Resident identifier: #29. Facility census: 150. Findings include: a) Resident #29 Record review revealed this [AGE] year old female was admitted to the facility in 2002. Her active [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] ([MEDICATION NAME]) 6.5 mg and 7 mg alternating every other day, according to the physician's monthly recapitulation of orders for October 2010. Review of a lab report, dated 10/07/10, for [MEDICATION NAME] time (PT) and international normalized ratio (INR), both of which were used to evaluate blood clotting time, found the PT to be high at 28.5 (normal range is 11.9 - 25.4) and the INR to be within normal limits (WNL) at 2.7 (normal range is 2.0 - 3.0). The physician was notified and ordered the same dosage of [MEDICATION NAME] with a recheck of labs in four (4) weeks. Previously, on 09/07/10, Resident #29 ' s PT was elevated at 25.9 and her INR was WNL at 2.1, and no change in medication was ordered. Review of the nursing notes found an entry, dated 10/10/10 at 6:15 p.m., stating the physician was notified that the resident had an increased temperature of 101.9 degrees Fahrenheit (F). The physician ordered Tylenol 500 mg and a urinalysis (UA) and complete blood count (CBC) stat. The results were called to the physician on 10/10/10 at 11:00 p.m., and the physician ordered Bactrim DS was ordered twice daily for seven (7) days. Her temperature at this time was 98.7 degrees F. Review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/12/10 at 1530 (3:30 p.m.), the nurse's notes indicated the resident's legal representative was notified of the resident having a urinary tract infection, of her increased temperature on 10/10/10, and of the new order for Bactrim DS. The resident's temperature at this time was noted at 97.0 degrees F. On 10/13/10 at 1:00 a.m., the nursing notes indicated the resident's was not having any signs or symptoms of adverse reactions associated with the use of the antibiotic. She remained afebrile, denied pain / discomfort, and was resting in bed with eyes closed. The next nursing note, written by a licensed practical nurse (LPN - Employee #137) and dated 10/14/10 at 7:20 a.m., stated, "Res(ident) found in floor @ bottom of bed. Res states she is OK, no visible injuries.... Res states she was going to the bathroom and fell , bed alarm was not on. Assessment completed, (symbol for 'no') c/o (complaint of) pain or discomfort. Will continue to monitor." In this same note, the nurse recorded her vital signs as follows: blood pressure (B/P) - 138/78; pulse - 78; respirations - 18; temperature - 98.8 degrees F; O2 sat was 93% on room air. Oxygen was reapplied, and her O2 sat was 95%. The next nursing note, written by a registered nurse (RN - Employee #166) and dated 10/15/10 at 3:20 p.m., stated, "Staff report pt (patient) had fall on 10/14/10. Noted bruising /c (with) hematoma to (L) (left) temporal area. Appeared to have difficulty opening (L) eye. Resident alert & speech clear. Pupils equal & reactive. B/P this am (morning) 136/64, O2 sat 90%, (pulse) 86, (respirations) 18. Dr. (name) notified & made aware of current status. Dr. (name) stated he was unaware of fall. New order received to send resident to (Hospital #1) ER for evaluation. Resident is currently on blood thinner. POA (power of attorney) was notified." The next nursing note, dated 10/15/10, at 4:15 p.m. stated, "TC from (Hospital #1) ER. Resident being sent to (Hospital #2); has a subarachnoid bleed." -- 2. Review of Hospital #1's records found Resident #29 had critical lab values of PT greater than 100 (normal range is 20.5 - 30.0, with critical values greater than 39), INR of 11.9 (normal range is 2.5 - 3.5, with critical values greater than 4.0), and PTT (partial [MEDICAL CONDITION] time) of 83 (normal range is 27 - 32) on 10/15/10 at 1526 (3:26 p.m.). The resident's red blood cells were low at 3.61 (normal range is 4.5 - 6.3), hemoglobin was low at 11.6 (normal range is 12.1 - 15), hematocrit was low at 33.9 (normal range is 35.8 - 46). The results of a CT scan of Resident #29's brain without contrast, dated 10/15/10, noted: "Findings: There is punctate hemorrhage of the left frontal lobe. There is no extra axial component. There is a large, left frontal scalp hematoma. Sulcal and ventricular prominence correlation with atrophy. There is no midline shift. There is no calvarial fracture." Under the heading CT Brain Impression was: "1. Acute left frontal lobe parenchymal hemorrhage. 2. Generalized cerebral atrophy. 3. Large, left, frontal scalp hematoma." The resident received 8 units of fresh frozen plasma and 30 mg of Vitamin K and was transferred to Hospital #2's neurology intensive care unit for a neurosurgical consultation on 10/15/10; she was subsequently admitted there at 2352 (11:52 p.m.), according to Hospital #2's discharge summary. -- 3. The discharge summary from Hospital #2, dated 10/20/10, under the heading Admission History and Physical stated: "This was a transfer from (Hospital #1). The patient initially is a resident at Heartland of Beckley. The patient apparently fell down. The patient was not taken to the hospital at that time. After a day (sic) refer to consultation with the family. The patient was sent to (Hospital #1). At Hospital #1, the patient was found to have (sic) subarachnoid hemorrhages. The patient was subsequently transferred to the Neuro ICU here at (Hospital #2) for neurological evaluation. On presentation to (Hospital #1), patient ' s blood pressure was 170/74. The patient's INR was noted to be 11.9. The patient did receive a course of Bactrim previously while at Heartland of Beckley." Under the heading Hospital Course was stated, "... I believe patient's subarachnoid hemorrhage is secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..." -- 4. Review of the resident's resident assessment protocol (RAP) for falls with an effective date and time of 06/29/10 at 11:09 a.m. stated, " ... resident was walking back from bathroom and slid and fell (sic) improper footware (sic) pt educated on use of proper footware (sic) improper footware (sic) removed (sic) assessed for injury (sic) none noted (sic) neuro checks started (sic) md and poa aware." An off-cycle falls RAP, with an effective date of 10/14/10 at 08:34 a.m., was completed by one (1) of the assistant directors of nursing (ADON - Employee #192) and signed on 10/16/10. It stated, "Fall care plan reviewed and remains in place. No new recommendations made during IDT (interdisciplinary team) review." - The Care Plan Focus for "At risk for falls due to Cognitive (sic) impairment, pain, unsteady gait, walks without assistance, low oxygen saturations from not wearing oxygen, [MEDICAL CONDITION]", which was initiated on 04/11/07, contained the goal of "No injury requiring transfer to hospital." The following interventions to achieve this goal were initiated on 04/11/07: "Monitor for and report development of pain, bruises, change in mental status, ADL function, appetite or neurological status for at least 72 hours after a fall. Administer medications as ordered and monitor for effectiveness. Minimize environmental clutter. Have commonly used articles within easy reach. Encourage to transfer and change positions slowly. Reinforce need to call for assistance. Encourage and assist as needed to wear proper and non slip footwear. Encourage to use assistive devices: walker." On 10/04/07, the IDT added: "Give medication as ordered." On 12/31/08, the IDT added: "Educate staff to not leave resident unattended." On 06/25/09, the IDT added: "Educate resident on the use of call light and asking for assistance." On 09/24/09, the IDT added: "Sensor pad to bed at all times." On 10/18/09, the IDT added, "Anti-rollbacks to W/C (wheelchair)." On 03/19/10, the IDT added: "non (sic) skid shoes as tolerate (sic)." (Note that several of the "newer" interventions were very similar to interventions that had been in place since 04/11/07.) - The Care Plan Focus for "Anticoagulant therapy to treat [MEDICAL CONDITION]: At risk for adverse effects", which was initiated on 04/11/07, contained the goal of "Resident will have no adverse effects from anticoagulant use such as (sic) not limited to bruising, bleeding, blood in stool / emesis, etc." Interventions to achieve this goal included: "Monitor lab values and report results to physician. Monitor for and reports (sic) adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Provide education to family / resident about safety precautions. Administer medications per physician orders. Monitor for S/S (signs / symptoms) of [MEDICAL CONDITION] such as pain (sic) redness in ext (extremities)." The last revision to this care plan was made on 10/27/09, beyond updating to the goal ' s target date. -- 5. The LPN who received the order from the physician on 10/10/10 at 11:00 p.m. (Employee #53) was interviewed at 9:57 a.m. on 10/27/10. Employee #53 said when she called the physician she did not tell him specifically what medications the resident was already receiving. She said the pharmacy usually calls before sending a medication if there would have been any problems with drug-to-drug interactions. - The nursing assistant (NA) who showered Resident #29 on day shift on 10/14/10 (Employee #31) was interviewed at 10:20 a.m. on 10/27/10. Employee #31 reported that, after lunch on 10/14/10, she noted a knot on the resident's head and bruising to the resident's hand, and the resident told her she fell . She said when she was on the way to the shower with the resident, she told the medication nurse (Employee #82, an LPN). He looked at the resident's head, administered a medication to the resident, and the resident was given a shower. Employee #31 said the resident was taken back to her room. She did note that the resident appeared to be having increased congestion. A review of Employee #31's statement taken by the director of care delivery (Employee #192) on 10/16/10 found the following: "States she took over care of resident on 10/14 AM (morning) when other CNA (certified nursing assistant) was pulled to another unit. State she saw a large raised area with a bruise stating to form on resident's (L) temple area. States this was around noon, during resident ' s shower. States she brought it to the attention of the nurse '(Employee #82 ' s first name)'. States resident's behavior was normal & speech was normal." Review of the Shower / Skin Observation Report for 10/14/10, completed by Employee #31 and signed by Employee #82, did not show any bruising or abnormalities for the resident. - The LPN who assessed Resident #29 after she was found on the floor at 7:20 a.m. on 10/14/10 (Employee #137) was interviewed at 10:25 a.m. on 10/27/10. She reported having been told of the fall by a NA (Employee #93) at the start of the shift. She said the resident was sitting in the floor upright with her legs out in front of her. The bed alarm was not on and was not sounding. She said she did a head-to-toe assessment of the resident and found no bruising or signs of injury. She indicated she checked the resident's head, back, and legs, as she was afraid the resident might have broken a hip. She also said she thought she started a neurological evaluation flow sheet but was told it could not be found. A review of Employee #137's statement taken by Employee #192 on 10/14/10 at 0830 (8:30 a.m.) found the following: "Nurse stated that resident had a fall around 0730 and that she found no apparent injuries. Stated resident denied any pain or discomfort. States she notified Dr. (name) and MPOA (medical power of attorney) of the fall and completed an incident report. State she initiated neuro checks because the fall was not witnessed. No noted abnormalities at that time." Elsewhere in witness statement for was written: "Staff member became ill shortly after the incident and was taken to the hospital by EMS. Unable to locate neuro check sheet." - The resident's October 2010 MAR indicated [REDACTED]. Review of the MAR for 10/14/10 found Employee #82 only gave the resident [MEDICATION NAME] 100 mg at 2:00 p.m. on that date, as he was reassigned to that area when Employee #137 was sent out to the emergency room . He stated, "(Employee #31) said the resident had a bruise on her head. I looked at it. I went out and looked at the book for acute documentation. I did not know if it was documented. I don't recall saying anything to (Employee #134) who I reported off to (at 3:00 p.m.)." A review of Employee #82's statement taken by Employee #192 on 10/16/10 found the following: "Stated he took over med cart for nurse that left due to illness, along with (Employee#134), LPN. States he did note a bruise to the L temple area of the resident, but (sic) had been told it was already there from a fall. States he did not know when the fall occurred." - An interview was conducted, on 10/27/10 at 11:30 p.m., with the LPN who received report from Employee #82 at 3:00 p.m. on 10/14/10 (Employee #134). Employee #134 said she worked from 7:30 to 4:00 p.m. on 10/14/10 as a treatment nurse. The October 2010 treatment record was reviewed with her at this time. She said she checked the resident's sensor pad and oxygen on 10/14/10, but she did not remember at what time. She thought it was before breakfast (before 8:30 a.m.). She reported that she helped Employee #82, after Employee #137 was sent out to the emergency room , with medications and doing treatments. She did not know anything about the resident's fall on 10/14/10. - A review of a statement taken from Resident #29 by Employee #192 on 10/15/10 revealed the following: "Resident sitting up on side of bed. Bruising noted to (L) temple / forehead area. Resident alert and answering appropriately to my questions. When asked if she had any pain, she answered, 'my head'. When asked if she remembered fall she stated, 'I'm not sure'. When asked where her head hurt she stated 'Inside and out'. Resident sent to (Hospital #1) within 30 minutes of my conversation with her." - A review of a statement taken from Employee #72 (a nursing assistant) by Employee #192 on 10/15/10 revealed the following: "CNA states that she noted a bruise to the (L) temple area of the resident around 0830 (8:30 a.m.) on the morning of 10/15/10 when she took her breakfast tray to her. States that the nurse was aware of the bruise at that time." - A review of a statement written on 10/18/10 by Employee #166 (a registered nurse assigned to Resident #29 on the morning of 10/15/10) revealed the following: "I had a wing and part of another wing (we were short nurses). I received report from night shift (name). No mention of a fall or injury to the resident was made during report. I gave her morning meds first. I noticed bruising to the left side of her temple area. I took her VS (vital signs) and they were normal. I had to wake her to take her meds. She was 'groggy' but sat up and took her pills for me. I questioned some other staff and they stated she had a fall the morning before. I assumed her bruising was from the fall. When I reviewed the chart there was no documentation of any injury. I recognized the resident was on [MEDICATION NAME]. I went to assess her neurologically and found her to be WNL but C/O pain to (L) eye. I notified Dr. (name) of fall (sic) 10/14 & injury noted @ this time. Dr. (name) stated he was not notified and asked that resident be sent to ER." -- 6. Review of the pharmacy manual's policy titled "Adverse Drug Reaction" from Omnicare, Inc (last revised 01/10/06), which was provided by the facility ' s administrator at approximately 9:00 a.m. on 10/27/10, found: "ROCEDURE: The pharmacy will identify potential ADRs (adverse drug recations) by reviewing any drug therapy that appeared to cause: - Discontinuation of therapy - Patient hospitalization - Treatment with another drug used for allergic reactions - Significant patient illness - Threat to life or death. "The pharmacist will document the potential adverse drug reaction on the Adverse Drug Reaction Log ... noting severity level. "The pharmacy operating system is set to identify First Data Bank (FDB) levels 1, 2, and 3 drug interactions for the dispensing pharmacist at the time of order entry. "The dispensing pharmacist evaluates the potential seriousness and immediacy of the drug interaction in the individual using their professional judgment and the information provided by FDB. Factors such as the person's age, comorbidities, and concurrent drug therapies area taken into consideration ..." "[MEDICATION NAME] Interactions: "a) Determine if the drug interaction potential is serious and predict the timing of the interaction as advised by FBD. "b) Recommend an alternate medication if possible ... or determine if a [MEDICATION NAME] dosage adjustment is indicated. Determine the appropriate INR monitoring frequency if needed. Call the facility and document the intervention ...." -- 7. Review of the facility's policy titled "Neurological: Neurological Evaluation" (dated 3/2010) found: "PURPOSE: A neurological evaluation is used to establish a baseline neurological status upon which subsequent evaluation may be compared and changes in neurological status may be determined. "USE: - Following a witnessed fall (when a patient has hit his/her head) - Following an un-witnessed fall (when a head injury may be suspected) - Following a patient event which results in a known or suspected head injury (i.e.: hemorrhagic stroke) ... "PROCEDURE: "1. Initiate and document a baseline neurological evaluation as indicated on the Neurological Evaluation Flow Sheet. "2. Notify physician of specific patient event, initial findings, and baseline neurological evaluation. "3. Obtain orders for subsequent neurological evaluations, diagnostic studies or other medical care. "4. After the completion of initial neurological evaluation with vital signs, continue evaluations every 30-minutes x 4, then every 1-hour x 4, then every 8-hours x 9 (for the next 72 hours). "NOTE: More frequent neurological evaluations may be necessary if clinically indicated or as ordered per physician. "5. Subsequent neurological evaluation should be compared to baseline and previous neurological evaluations. "6. Evaluate level of consciousness and document 'Y = Yes or N = No' responses to the following: - Alert - Lethargic - Semi-comatose - Comatose "7. Evaluate level of orientation and document 'Y = Yes or N = No' responses to the following: - Oriented to person - Oriented to place - Oriented to situation "8. Evaluate pupils. (It may be necessary to darken room or ask patient to close eyes for 30 seconds prior to evaluation.) Upon opening eyes, use a penlight or flashlight to evaluate Pupil Size and Pupil reaction for both the left and right eyes. Document using the following responses: - E = equal pupil size - U = unequal pupil size - R = reacts to light - NR = no reaction to light "9. Evaluate motor movement by providing patient with simple motor commands. Document 'Y = Yes or N = No' responses to the following: - Moves right upper limb - Moves left upper limb - Moves right lower limb - Moves left lower limb - Facial symmetry "10. Evaluate communication / language by providing simple communication commands. Document 'Y = Yes or N = No' responses to the following: - [MEDICAL CONDITION] - Receptive [MEDICAL CONDITION] - Speech slurred - Communication changes "11. Evaluate for unusual / new observations. Document observation responses using the following: - W = Weakness - T = Tremors - D = Dizziness - H = Headache - V = Vision changes - N = Numbness - O = Other "12. Evaluate vital signs. Record baseline vital signs and compare subsequent vital signs to baseline and previous evaluations. Document the following information: - Blood pressure - Pulse - Pulse Ox % (Oxygen Saturation) - Temperature - Respiration rate - Respiration pattern -- N = Normal / Regular / Unlabored -- AB = Abnormal (i.e.: Labored, Kussmaul's , Cheyne-Stokes or Apnea) "NOTE: Pay close attention to respiratory patterns. Notify physician regarding any 'Abnormal' findings or any changes in respiration rate or pattern. "NOTE: Notify physician of any neurological evaluation findings which are a change from baseline or previous evaluations. Document physician notification in Progress Notes. "13. Notify the family / caregiver of patient condition an devaluation findings. "14. Communicate event, interactions, and plan of actions using center specific systems (i.e. shift to shift reports, 24-Hour Reports, Eagle Room team meeting and alert charting)" - Random confidential nursing staff interviews found that evidence of ongoing neurological evaluations of Resident #29 could not be found. Although Employee #137 (who first assessed her after she was found on the floor on the morning of 10/14/10) reported she completed an initial neurological exam, evidence of that initial assessment could not be found. This lack of on-going neurologic assessments was confirmed during an interview at exit with the facility administrator at 4:30 p.m. on 11/02/10. -- 8. The facility's "Practice Models Charting Alert" (dated 08/11/06) stated: "Purpose: To provide a guideline for the clinical documentation process that may be needed following a change in patient condition or status "Guidelines: The alert charging process includes documentation of a patient's condition that warrants alert charging, the decisions and actions of staff related to the patient's condition and the patient's response to interventions implemented - Situation for alert charting typically include new admission monitoring needs, acute change of patient condition or situations that are expected to resolve or stabilize within. Some examples may include, but are not limited to: -- Change of condition, e.g. flu symptoms -- Accidents -- New admission or re-admissions -- Signs and symptoms of infection -- Skin alterations, e.g., skin tear, bruise, rash - The Alert Charting process includes, but is not limited: -- Documentation of patient evaluation findings, physician notifications and responses, family notification and any new orders or instructions received in the interdisciplinary progress notes or nursing notes -- Initiation of an Acute Care Plan including the patient ' s problem or need, goal, and interventions planned to manage the patient ' s condition -- Addition of patient name and information to the Alert Charting Log -- Update to the Change in Status Report, 24-hour Report -- Inclusion of information in shift-to shift report -- Notification of nurse supervisor, IDT members and other staff as needed -- Review of patient status during Eagle Room meetings - Documentation for alert charting occurs each shift for a minimum of 72 hours - Licensed nurses reference the Alert Charting Log at the start of each shift to identify patients requiring continued follow-up and alert documentation - Documentation related to the alert charting process may include, but is not limited to: -- Patient evaluation pertinent to the condition identified as the acute event -- Vital signs -- Presence or absence of pain -- Complaints and/ or behavior problems -- Changes in activities of daily living -- Patient response or outcomes - Remove patients form Alert Charting Log and discontinue Acute Care Plan when patient status has stabilized or the condition or symptom has resolved." There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. Review of the "Change In Status Worksheet / 24 Hour Report" for 10/10/10 through 10/14/10 revealed no mention of Resident #29's condition and/or status except for on 10/10/10, when a nurse wrote: "Give Tylenol 500 mg PO now D/T (due to) increased temp. U/A and CBC stat." - The "Change In Status Worksheet, 24-Hour Report Practice Model" (dated 08/11/06) stated: "Purpose: To provide an interdisciplinary communication tool that may be used to identify patient with a change in condition requiring intervention and follow-up. "Guideline: "- Complete form per directions and use narrative section for additional information as needed "- Information includes but is not limited to: -- Admissions -- Unplanned discharges -- Change in condition, e.g. improvement or deterioration in physical, mental and psychological status -- Unstable condition -- Incidents / accidents -- New / discontinued medication orders -- Abnormal lab results -- Pain level > or = 4 -- Patient / family concerns -- Notification of physician, family / responsible party, administrator and/or ADNS -- Documentation completed: Nursing admission evaluation, off-cycle RAP, progress RAP, progress notes -- Nurse's initials "- Interdisciplinary team members may enter any identified change of condition requiring clinical follow-up "- Use report to communicate concerns at morning and after Eagle Room meetings "- Use report during shift change to communicate patient information and needed follow up "- Review report to confirm follow-up, notification and documentation of patient needs are complete" - There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. -- 10. Review of the pharmacy manual's "Policy #4.1 Prescriber Authorization and Communication of Orders" (dated 12/01/07) found: "PROCEDURE: " ... 3. Verbal Orders: "3.1 The facility's licensed nurses should contact the resident's physician where there is a change in condition that may require a new medication or a renewal of an existing order. "3.1.1. Before contacting the physician / prescriber, the Facility's licensed nurses should assemble the necessary clinical information. This information may include, but is not limited to: vital signs, recent laboratory or diagnostic study results, recent medication orders, residents' response to medication, and possible adverse drug reactions." No one at the facility recognized the possible adverse drug reaction associated with simultaneously administering Bactrim DS with [MEDICATION NAME]. . | 2014-03-01 |