**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that services were provided that met professional standards of quality for 6 Resident (#1, #2, #3, #10, #13 and #14), from a total of 17 residents.
Findings include:
1. For Resident #1, the facility failed (a) to ensure that a medication with a stop date was reassessed to prevent the medication from being administrated which resulted in a medication error; (b) the facility failed to ensure a new physician’s orders [REDACTED].
Resident #1 was admitted to the facility in 10/2016 with [DIAGNOSES REDACTED]. During review of the physician’s orders [REDACTED]. The order indicated the staff were to start the medication on 5/4/17, administer through 7/4/17, and have the physician re-evaluate the medication on 7/4/17.
On 7/6/17, the Surveyor observed the Medication Administration Records (MAR) for 5/2017, 6/2017 and 7/2017 for Resident #1. The MARs indicated that the [MEDICATION NAME] was transcribed onto the MAR and included the time frame for administration of the [MEDICATION NAME] which indicated the medication was to be stopped on 7/4/17 and reassessed by the physician (before continuing the administration of the medication). Review of the 7/2017 MAR indicated that the [MEDICATION NAME] was administered for 2 days, after the stop date on 7/5/17 and 7/6/17. Further review of the medical record failed to indicated the nursing staff contacted the physician and obtained an order to continue the medication.
During interview on 7/6/17 at 2:40 P.M., Unit Manager #1 (UM #1) said she was aware that the facility staff had not contacted the physician on 7/4/17. UM #1 said she had contacted the physician on 7/6/17. The UM said (and according to the Facility policy for Transcribing Physician Orders) the staff are suppose to block off the stop date on the MAR to prevent the medication being administered without a reassessment and causing a medication error.
(b) Review of the physician orders [REDACTED]. Review of the 3/2017 MAR indicated the medication was discontinued, as evident of a physician order [REDACTED]. Observation of the 4/2017 MAR indicated the medication was not included on MAR. On 7/6/17, the Surveyor observed the Medication Administration Records (MAR) for 5/2017. According to the observation, the staff hand transcribed the medication [MEDICATION NAME] 50 mg, PRN onto the MAR. The staff signed that the medication was administered on 5/15/17, 5/20/17 and 5/23/17. Review of the clinical record failed to indicate the staff obtained a physician order [REDACTED]. During interview on 7/7/17 at 10:40 A.M., Unit Manager #1 (UM #1) said that the nurse had not obtained a reinstatement order and caused a discontinued medication to be administered.
(c) Review of the physician orders [REDACTED]. Observation of the 4/2017 MAR indicated that the staff documented that the supplement was discontinued on 4/11/17 Review of the 5/2017, 6/2017 and 7/2017 MARs indicated the staff failed to ensure that the supplement was discontinued. According to the MARs for these 3 months indicated the Resident was administered the frozen supplement three times daily without a physician order. During interview on 7/6/17 at 2:40 P.M., the information was shared with the UM #1. She said the staff during editing should have ensured the supplement was discontinued from the MAR and orders.
2. For Resident #2, the facility failed to ensure that the Resident received the antidepressant medication [MEDICATION NAME] as ordered by the physician. Resident #2 was admitted in 8/2015 and had [DIAGNOSES REDACTED]. Review of the medical record on 7/7/17 indicated the Resident’s medications included the antidepressant medication [MEDICATION NAME] be administered daily (30 mg). Review of the 5/2017 MAR indicated that the medication [MEDICATION NAME] had not been administered 19 out of 31 times. Further review indicated that the medication was refused by the Resident on 3 occasions and administered as ordered on 9 occasions. The medical record including nurses notes and physician notes failed to indicate why the medication had not been administered. During an interview on 7/7/17 at 10:40 A.M. the Unit Manager (#1) said she did not know why the medication had not been administered as ordered. During a follow-up interview on 7/10/17 at 2:40 P.M. UM #1 had no additional information about the staffs not administering the [MEDICATION NAME].
3. For Resident #3, the facility failed to meet professional standards of quality by failing to document the actual time of the medication administration of [MEDICATION NAME] (a [MEDICAL TREATMENT] medication). Resident #3 was admitted to the facility in 7/2016 with [DIAGNOSES REDACTED]. The Resident goes out of the facility to a [MEDICAL TREATMENT] clinic three times a week (leaves at 6:15 A.M. and returns at 10:30 A.M.) for [MEDICAL TREATMENT]. On 7/6/17 during the medication pass observation at 9:00 A.M., the Surveyor observed the Medication Administration Record (MAR) for Resident #3. The MAR indicated that [MEDICATION NAME] was to be administered at 8:00 A.M., but had not been signed off as given. Review of the physician’s orders [REDACTED]. by mouth everyday with meals, but on [MEDICAL TREATMENT] days, with breakfast ([MEDICATION NAME] is used to control serum phosphorus levels in people with [MEDICAL CONDITION] who are on [MEDICAL TREATMENT]. [MEDICATION NAME] binds to phosphorus in the foods you eat so your body doesn’t absorb as much and therefore, needs to be taken with meals per the manufacturer’s specifications.). Review of the MAR for 6/2017 and 7/2017 indicated that all staff were documenting that [MEDICATION NAME] was administered at 8:00 A.M. everyday, despite that the Resident was at [MEDICAL TREATMENT] 3 days per week from 6:15 A.M. to 10:30 A.M. The Surveyor interviewed Nurse #1 on 7/6/17, shortly after the medication pass observation. Nurse #1 said that the Resident did get breakfast before [MEDICAL TREATMENT] three days per week, but that the Resident did not receive [MEDICATION NAME] until he/she returned from [MEDICAL TREATMENT]. Nurse #1 did not know the significance of taking the medication with meals. Nurse #1 also said that she signed off that the [MEDICATION NAME] was administered at 8:00 A.M., despite actually being administered upon return from [MEDICAL TREATMENT] at approximately 10:30 A.M., three days per week. According to Centers for Medicare and Medicaid (CMS) standards of practice are integral to the provision of appropriate medication therapy for nursing facility residents. The standards of practice are designed to fulfill Federal mandates to:
· Decrease medication errors and adverse drug events;
· Assure proper medication selection;
· Monitor drug interactions, over-medication, and under-medication;
· Improve the documentation of medication administration.
4. For Resident #10, (a) the staff administered medications that had been identified as a medication the Resident was allergic to; and (b) the facility failed to obtain parameters as to notification of the physician when the Resident became either hypoglycemic (low blood sugar) or hyperglycemic (high blood sugar) Resident #10 was admitted in 1/2015 with [DIAGNOSES REDACTED].
(a) Review of the medical record, including the hospital discharge record dated 9/27/16 indicated the Resident had multiple medication’s allergies [REDACTED]. Review of the 6/2017 and 7/2017 physician orders [REDACTED]. [REDACTED]. During interview on 7/11/17 at the Director of Nurses was asked about the procedure for medications identified as an allergy. She said that staff were to notify the physician for instruction.
(b) Review of the physician orders [REDACTED].#10 was administered the oral anti-diabetic medication [MEDICATION NAME] 5 mg daily and the staff were to obtain Fingerstick blood sugars (FSBS) twice a day at 6:30 AM. and 4:30 P.M. There was no sliding scale and the facility failed to obtain parameters as to notification of the physician when the Resident became either hypoglycemic (low blood sugar) or hyperglycemic (high blood sugar). Review of the Resident #10’s 7/2017 Diabetic Monitoring Record indicated that his/her blood sugars results ranged from 98 mg/dL to 275 mg/dL; and 15 results were over 126 mg/dL, 5 results were over 150 mg/dL, 3 results were over 200 mg/dL and 1 result was over 250 mg/dL. According to the American Diabetic Association a normal blood sugar range was below 126 mg/dL. During interview on 7/10/17 at 10:40 A.M., UM #1 said that there were no parameters for either high or low blood sugars for the Resident.
5. For Resident #13, the facility staff failed to follow the Facility’s Policy and Procedure for anticoagulation therapy, by failing to daily assess the injection site and rotating the injection site. Resident #13 was admitted to the facility in 5/2017 and had [DIAGNOSES REDACTED]. Review of the closed medical record on 7/10/17 indicated the physician ordered the anticoagulant medication [MEDICATION NAME] 0.7 ml, subcutaneous, twice daily. Review of the medical record including the 5/2017 MAR and nurses notes failed to indicate the Staff were monitoring and rotating the injection site. The MAR indicated the medication was administered but failed to indicate the location. During review of the medical record with the Director of Nurses on 7/11/17 at 11:20 A.M., she said that the nursing staff (and according to the Facility policy) were to rotate the injection cite when administering a subcutaneous anticoagulant.
6. For Resident #14, the staff administered a medication that had been identified as a medication the Resident was allergic to. Resident #14 was admitted in 5/2017 with [DIAGNOSES REDACTED]. Review of the closed medical record, including the hospital discharge record dated 5/2/17, indicated the Resident had multiple medication’s allergies [REDACTED]. Review of the physician orders [REDACTED]. On 5/3/17, the psychiatric consultant noted the allergy to the medication in his assessment. The assessment indicated he question what the medication allergy was and noted it may (?) cause a rash. Subsequent review of the clinical record failed to indicate the Facility staff identified the problem and they subsequently administered the medication from 5/2/17 through 6/8/17, without evidence they were monitoring for an allergic reaction to the medication. During interview on 7/11/17 at the Director of Nurses was asked about the procedure for medications identified as an allergy. She said that staff were to notify the physician for instruction.