cms_WY: 15
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 15 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2019-08-21 | 760 | D | 1 | 0 | OB2411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, medication error report review, staff interview, and quality assurance information review, the facility failed to ensure residents were free of significant medication errors for 2 of 11 sample residents (#1, #3) reviewed for medication regimen. Corrective measures were implemented by the facility prior to the survey and substantial compliance was determined to be achieved on 7/17/19. The findings were: 1. Review of the 6/27/19 admission orders [REDACTED]. The resident also had an order for [REDACTED]. Review of the 5/22/19 admission orders [REDACTED]. The following concerns were identified: a. Review of the (MONTH) 2019 MAR (medication administration record) showed the resident did not receive scheduled [MEDICATION NAME] for the 8 AM dose on 7/4/19, 7/5/19, and 7/6/19. In addition, the resident did not receive the scheduled [MEDICATION NAME] for the 8 PM dose on 7/1/19, 7/3/19, 7/5/19, and 7/6/19. The review showed no documented explanation for the omitted medication. Review of the corresponding medication error report dated 7/8/19 and timed 7:36 AM showed Upon review of MAR and MD orders = noted a total of 7 doses of [MEDICATION NAME] missed since 7/1/19. b. Review of an order communication from the nurse practitioner on 7/6/19 at 4:21 PM showed Is (the resident) still on [MEDICATION NAME]? Increase [MEDICATION NAME] to 7.5 mg tonight and Tuesday, recheck next Saturday. Review of an interdisciplinary progress note dated 7/7/19 and timed 6AM-6PM showed Clarification order written for [MEDICATION NAME] order. Spoke with (nurse practitioner). Review of the (MONTH) 2019 MAR showed the order to increase the resident's [MEDICATION NAME] to 7.5 mg was not started until 7/7/19 at 4 PM, 23 hours and 39 minutes after the order was written. Review of the corresponding medication error report dated 7/7/19 timed 2:30 PM showed When going thru faxes on the desk found orders that hadn't been taken off regarding new [MEDICATION NAME] orders from pt/inr results from 7/5/19. This nurse also found [MEDICATION NAME] had not been given. This nurse called on call relayed what I had found and obtained new orders and carried them out. c. Review of the 6/27/19 admission orders [REDACTED]. Review of a 7/9/19 interdisciplinary progress note timed 6 AM-6 PM revealed the nurse discovered an order for [REDACTED]. Review of a medication error report dated 7/9/19 and timed at 4:35 PM showed the nurse discovered an order dated 7/5/19 to increase the resident's [MEDICATION NAME] to 10 mg QID. Review of the (MONTH) 2019 MAR showed the facility failed to increase the [MEDICATION NAME] to 10 mg QID until 7/9/19 at 12 AM. d. Interview with the administrator and the director of nursing (DON) on 8/20/19 at 10:40 AM confirmed the facility failed to administer all doses of [MEDICATION NAME] as ordered, and failed to follow the nurse practitioner's order to increase the resident's [MEDICATION NAME] in a timely manner. In addition, they confirmed the resident's [MEDICATION NAME] order was not revised to reflect the increase in dosage in a timely manner. 2. Review of a fax from a nurse practitioner dated 6/13/19 and signed at 11:48 AM for resident #3 showed [MEDICATION NAME] (antibiotic) 1 gm for two doses was ordered. The following concerns were identified: a. Review of an interdisciplinary progress note dated 6/19/19 and signed at 11:20 AM showed Order clarified and received to give [MEDICATION NAME] 1 gm IM (intramuscular injection) times 2 doses. First dose given today for UTI (urinary tract infection) with no adverse reactions . Review of the (MONTH) 2019 MAR showed the [MEDICATION NAME] was administered on 6/19/19 and 6/20/19. b. Interview with the administrator and DON on 8/20/19 at 10:40 AM confirmed the facility failed to administer the resident's [MEDICATION NAME] in a timely manner. 3. Interview with the administrator and DON on 8/20/19 at 10:40 AM confirmed the facility had identified issues with the medication system. On 7/15/19 the facility addressed the issue with a Quality Assurance Performance Improvement (QAPI) Action Plan. The actions taken were as follows: a. Review of the 7/15/19 QAPI Action Plan to address medication errors showed transcription of medication from fax orders to telephone orders to the MAR/treatment administration record (TAR) was identified as the main issue. The plan identified specific staff members as having issues with orders, and the DON would address these issues with specific staff members, and also provide general staff education. The DON and the unit managers, along with other staff members designated by the DON, would be responsible for conducting audits. b. Review of the 7/17/19 Mandatory Nurses Meeting documentation showed nurses were educated on issues regarding medication errors and delay of transcription of orders. Nineteen nurses signed the attendance form. c. Review of the completed Medication Errors Audit forms showed a variety of nurses participated in the audits and all units were included. The audit dates were from 7/17/19 to 8/22/19. The 3 categories on the form included, Medication orders include dosage, route, time, and diagnosis, Medication transcribed to MAR/TAR, and Medication signed as given on the MAR/TAR. At the top of the forms the requirement was, 10 residents 3 times per week. 4. Review of the medical record for 11 sample residents showed no medication issues were identified after the 7/17/19 education was provided to nurses and the audit process began. | 2020-09-01 |