cms_AK: 7
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
7 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2017-05-19 | 332 | D | 0 | 1 | YBQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure 2 residents (#s 12 and 13), out of 5 residents observed during medication administration, received medications per physician's orders [REDACTED].#12) was given a medication without measuring blood pressure prior to administration per physician's orders [REDACTED].#13) was given a medication that was administered contrary to manufacturer recommendation and physician order, specifically crushed vs. whole. This failed practice placed the facility's medication error rate above 5% and placed the resident at risk for not receiving therapeutic benefits from the medications. Findings: Resident #12 Record review on 5/16-18/17 revealed Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review on 5/16/17 revealed Resident #12's medication regime included the Resident had an order for [REDACTED]. Observation during a medication pass on 5/16/17 at 12:00 noon, revealed LN #2 entered Resident #12's blood pressure results in the Medication Administration Record [REDACTED]. During an interview on 5/16/17 at 12:00 noon, licensed nurse (LN) #2 stated he/she only takes Resident #12's blood pressure in the morning and the afternoon. The LN further stated Resident #12's blood pressure was always high. During an interview on 5/18/17 at 8:30 am, LN #3 reviewed the order and stated Resident #12's blood pressure should be taken prior to giving [MEDICATION NAME]. During an interview on 5/17/17 at 3:30 pm, Pharmacist (PH) #2 stated the blood pressure should be taken within 1 hour of giving the blood pressure medication [MEDICATION NAME]. He/she further stated the blood pressure reading from the prior dose should not be used for the current dose. Resident #13 Record review on 5/16-19/17 revealed Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 5/18/17 revealed Resident #13's medication regime included Aspirin EC ([MEDICATION NAME] coated) 81mg (milligrams) po (by mouth) QD (every day) Admin (Administration) Instructions: Do not crush. Observation of a medication pass on 5/16/17 at 10:30 am revealed, LN #1 crushed Resident #13's medications which included the [MEDICATION NAME] coated aspirin. During an interview on 5/17/17 at 3:15 pm, PH #2 stated that [MEDICATION NAME] coated aspirin shouldn't be crushed. Review of the WebMD website http://www.webmd.com/drugs/2/drug- -3/aspirin-ec/details, accessed on 5/25/17, revealed: Swallow [MEDICATION NAME]-coated tablets whole. Do not crush or chew [MEDICATION NAME]-coated tablets. | 2020-09-01 |