cms_AL: 70
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
70 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2020-03-03 | 842 | D | 1 | 1 | LZCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of a facility policy titled Medication: Administration: General, the facility failed to ensure nursing staff documented administration of Resident Identifier (RI) #24's [MEDICATION NAME] on 01/28/20 and 01/30/20 on the Medication Administration Record (MAR). This affected 1 of 20 sampled residents whose MARs were reviewed. Findings Include: A review of a facility policy titled Medication: Administration: General, revised [DATE], documented: .11. Document: 11.1 Administration of medication on Medication Administration Record (MAR). RI # 24 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #24's physician's orders [REDACTED]. A review of RI # 24's Narcotic Record for January 2020 documented one dose of [MEDICATION NAME] was taken out on 1/28/20 and another on 1/30/20. However, review of RI # 24's January 2020 MAR did not reflect [MEDICATION NAME] was administered on [DATE] or 1/30/20. On 3/1/20 at 5:00 p.m., an interview was conducted with Employee Identifier (EI) # 5, the Licensed Practical Nurse (LPN) that signed out the [MEDICATION NAME] on 1/28/20. EI # 5 was asked if she gave RI # 24 a [MEDICATION NAME] on 1/28/20. EI # 5 stated yes, it was documented on the narcotic book that she had signed one out. EI # 5 was asked if she marked the MAR when the [MEDICATION NAME] was given on 1/28/20. EI # 5 stated no, she forgot, but she should have signed it off on the MAR as adminsitered. EI # 5 was asked why she should mark it on the MAR. EI # 5 stated the next shift needed to know what was given. EI # 5 was asked how many doses of the [MEDICATION NAME] RI # 24 received. EI # 5 stated a total of two doses: one on 1/28/20 at 6:00 p.m. and one on 1/30/20 at 12:00 p.m. EI # 5 stated she did not give the the dose on 1/30/20. EI # 5 was asked if the nurse from 1/30/20 marked on the MAR that the [MEDICATION NAME] was given. EI # 5 stated no. An interview was completed with EI # 4, Registered Nurse/Unit Manager, on 3/3/20 at 9:40 a.m. When questioned about RI #24's Narcotic Record reflecting doses of [MEDICATION NAME] were signed out on 1/28/20 and 1/30/20 but administration was not documented on the MAR, EI # 4 stated it should have been documented in both places. EI #4 further explained the Narcotic Record reflected the medication was taken out, and the MAR should reflect the medication was administered. EI # 4 was asked if nurses should document on the MAR when they give medications. EI # 4 replied yes. EI # 4 was asked why nurses should document on the MAR. EI # 4 replied, to show the medication was given. | 2020-09-01 |