| 21 |
SANTA ROSA CARE CENTER |
35004 |
1650 NORTH SANTA ROSA AVENUE |
TUCSON |
AZ |
85712 |
2017-10-05 |
281 |
E |
0 |
1 |
2ZZS11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, interviews, and policy and procedures, the facility failed to ensure that one resident (#121) was provided a medication through a PEG (percutaneous endoscopic Gastrostomy) tube in a safe manner and failed to ensure narcotic medications were signed as administered immediately after administering the medications. Findings include: Resident #121 was readmitted (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's orders [REDACTED]. A Minimum Data Set (MDS) assessment dated (MONTH) 27, (YEAR), revealed the resident was unable to answer questions, the resident had a PEG tube, and the resident was on a mechanically altered diet. A medication administration observation was conducted on (MONTH) 2, (YEAR) at 11:20 a.m. with a licensed practical nurse (staff #70). During the observation, the nurse flushed the PEG tube with 80 cc. of water using a 60 cc syringe prior to administering a medication, mixed a crushed pill with 30 cc of water and pushed it into the tube, and pushed another 80 cc of water into the tube after administering the medication. However, the nurse depressed the plunger on the syringe to push the water and medication into the resident's PEG tube, rather than removing the plunger on the syringe, pouring the water and medication into the syringe, and allowing gravity to allow the water and medication to flow into the PEG tube. During an interview with staff #70 conducted on (MONTH) 2, (YEAR) at 11:25 a.m., the nurse stated that she did not know if she was supposed to use the plunger on the 60 cc syringe to push the flushes and the medication into the PEG tube, or remove the plunger on the syringe and allow gravity to pull the flushes and the medication into the PEG tube. The nurse stated that she had been provided training regarding how to administer medications into a PEG tube, and that she would review the facility's policy. During an interview with staff #70 conducted on (MONTH) 2, (YEAR) at 11:40 a.m., the nurse stated that she had review the policy and that she should have removed the plunger on the syringe and allowed gravity to pull the flushes and the medication into the PEG tube, and not pushed the water and medication into the tube. The policy Enteral Tubes included the statement Allow medication to flow down tube via gravity. -During a review of the controlled substance sheets conducted (MONTH) 4, (YEAR) at 1:03 p.m. with Licensed Practical Nurse (LPN/staff #45), it was observed that 6 narcotic controlled count sheets did not match the 6 narcotic count medication cards. The narcotic count medication card had less than indicated on the narcotic controlled count sheets. Review of the Medication Administration Record (MAR) for these six narcotics revealed 3 had been initialed as having been administered on the MAR and 3 were not. Staff #45 stated he administered the medications and proceeded to sign the narcotic controlled count sheets and the MAR indicating that the medications had been administered. Continued observation with staff #45 revealed another narcotic count medication card had one more narcotic than the narcotic controlled count sheet. Staff #45 stated he signed out the narcotic on the narcotic controlled count sheet by mistake because he usually works the evening shift. An observation was conducted (MONTH) 4, (YEAR) at 1:13 p.m. with staff #45. Review of the narcotic controlled count sheet revealed that a dose of [MEDICATION NAME] extended release 15 milligrams was signed out by staff# 45 at 8 a.m. and that the remaining doses should be 25, however, it was observed that there was 26 doses remaining of the medication. Review of the MAR revealed the medication was initialed as administered. Staff #45 stated I must not have given it. An interview was conducted with staff #45 on (MONTH) 4, (YEAR) immediately following the above observations. He stated that the expectation is that the nurse signed out the medication immediately after the medication is administered. He further stated that as a result of not administrating the scheduled narcotic medication he would need to evaluate the resident for pain, notify his supervisor, and then follow the direction given by the physician. An interview was conducted with the Director of Nurses (DON/staff #107) on (MONTH) 4, (YEAR) at 1:26 p.m. He stated that the expectation is that the nurse is to sign out a medication as soon as it is administered. Staff #107 also stated he expects the nurses to observe the five rights of medication administration which are: the right patient, the right drug, the right dose, the right route, and the right time. He further stated that medication administration is supervised by the Unit Coordinators on each unit to assure compliance with policy. An interview was conducted with the Unit Coordinator (LPN/staff #113) on (MONTH) 5, (YEAR) at 10:39 a.m. He stated that the expectation is that the nurses follow the five rights of medication administration when administering medication. The policy Medication Administration included medications are administered as prescribed, medications are administered within 60 minutes of scheduled time unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. The individual who administers the medication dose records the administration on the resident's MAR immediately following the medication being given. |
2020-09-01 |