cms_AZ: 39
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 39 | DESERT TERRACE HEALTHCARE CENTER | 35014 | 2509 NORTH 24TH STREET | PHOENIX | AZ | 85008 | 2017-12-05 | 761 | D | 0 | 1 | 6GPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility documentation, staff and resident interviews, and policy and procedures, the facility failed to ensure that medications for two residents (#54 and #144) were secured in a locked storage area and were only accessible to authorized personnel. Findings include: -Resident #54 was admitted on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR) revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. An observation was conducted in the resident's room on (MONTH) 29, (YEAR) at 9:08 a.m. A vial of [MEDICATION NAME] Nebulizing Solution was observed on the bedside table. The resident stated that the medication was left by a nurse (LPN/staff #46) the night before. At this time, a Licensed Practical Nurse (LPN/staff #63) entered the resident's room and the resident notified her of the presence of the medication. The nurse then removed the medication from the bedside table and placed it in her pocket and left the room. Following this, an interview was conducted with staff #63. She stated that it was the first time she had been in the resident's room that day and that the medication was [MEDICATION NAME]. An interview was conducted with the Director of Nursing (DON/staff #66) on (MONTH) 5, (YEAR) at 9:08 a.m. She stated that staff are never to leave medications at the bedside. She stated that staff are expected to observe residents taking the medication before leaving the room. She stated the nurses have received training on medication storage and that training and reminders are ongoing. An interview was conducted with LPN (staff #46) on (MONTH) 5, (YEAR) at 2:38 p.m. She stated that she forgot and left the [MEDICATION NAME] at the bedside. She stated the policy and expectation in the facility is not to leave medication at the bedside. She stated that she knows not to leave medication at the bedside. -Resident #144 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed an admission assessement dated (MONTH) 27, (YEAR), which documented the resident was alert and oriented times three and did not desire to self administer drugs. An observation was conducted on (MONTH) 29, (YEAR) at 9:52 a.m., of resident #144's room. At this time, one bottle of multi-vitamins with minerals was observed on the resident's bedside table. The resident stated that he purchased them and no one from the facility had said anything about them. Review of the label on the vitamin bottle revealed the following: DG Complete 100 IU (International Units) Vitamin D adults over 50 multi-vitamin with minerals. Review of the admission physician's orders [REDACTED]. An interview was conducted on (MONTH) 29, (YEAR) at 10:10 a.m., with a registered nurse (staff #45). Staff #45 reviewed the physician's orders [REDACTED]. Staff #45 stated she had not noticed the vitamin bottle in the resident's room and that it should have been removed. She stated the physician should have been notified regarding an order for [REDACTED]. Review of a facility policy on Medication Access and Storage revealed to store all drugs in locked compartments and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. | 2020-09-01 |