cms_AZ: 45
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 45 | HANDMAKER HOME FOR THE AGING | 35016 | 2221 NORTH ROSEMONT BOULEVARD | TUCSON | AZ | 85712 | 2019-01-08 | 758 | E | 0 | 1 | ZWO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews and staff interviews, the facility failed to ensure there was adequate monitoring for adverse side effects for three residents (#10, #52 and #171) on [MEDICAL CONDITION] medications and failed to monitor target behaviors for one resident (#52) on an antidepressant medication. Findings include: -Resident #10 was admitted on (MONTH) 30, (YEAR) and readmitted on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 8, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also included the resident received antipsychotic medication 7 of 7 days and antidepressant medication 6 of 7 days of the lookback period. A review of the resident's care plan regarding the use of [MEDICAL CONDITION] medications included a goal that the resident would remain free of complications related to [MEDICAL CONDITION] drugs. Interventions were to monitor for side effects and effectiveness each shift and to monitor/document/report as needed any adverse reactions of [MEDICAL CONDITION] medications such as: unsteady gait, tardive dyskinesia, shuffling gate, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, [MEDICAL CONDITION], social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting and behavioral symptoms not usual to the person. The physician orders [REDACTED]. The orders did not include to monitor for adverse effects of these medications. Review of the Pharmacist New Admission Medication Review dated (MONTH) 10, (YEAR) revealed a recommendation to the physician/prescriber which stated [MEDICATION NAME] and [MEDICATION NAME] in combination may increase the risk of serotoni[DIAGNOSES REDACTED], if either drug is increased in dose/frequency, monitor for adverse events. A review of the Nurse Practitioner hospital discharge follow up note dated (MONTH) 11, (YEAR) revealed a medication review and an assessment of major [MEDICAL CONDITION], with a plan to follow response to medications and circumstances. Further review of the clinical record revealed a form titled, Side Effects Monthly Flow Sheet for (MONTH) 2019. The form included instructions to use the form for the following medication classes: antianxiety, antidepressant, antipsychotic and sedative/hypnotic. This form also included the side effects/adverse effects of each of these drug classes, with areas to document if any adverse effects. This form was blank. In addition, there was no clinical record documentation that the resident was being monitored for adverse effects of the [MEDICAL CONDITION] medications in (MONTH) (YEAR) and (MONTH) 2019. -Resident #171 was admitted on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. The orders did not include to monitor for any adverse effects of the medications. A baseline care plan identified a focus area related to a mood problem. Interventions included to administer medications as ordered, and to monitor/document for side effects and effectiveness. Review of the clinical record revealed there was no documentation that the resident was consistently monitored for adverse side effects related to the use of [MEDICAL CONDITION] medications. An interview was conducted with Licensed Practical Nurse (LPN/staff #53) on (MONTH) 6, 2019 at 1:30 p.m. Staff #53 stated the nurses are to document on the Side Effects Monthly Flow Sheets that are placed in the book. She said that she was not sure who was responsible to place the forms in the book. She also stated that she was unable to find documentation that resident #10 and #171 were being consistently monitored for adverse effects of [MEDICAL CONDITION] medications. -Resident #52 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. An informed consent was obtained for the use of [MEDICATION NAME] on (MONTH) 10, (YEAR). Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 14, (YEAR), revealed the resident scored a 9 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The MDS assessment further documented that the resident had received an antidepressant for seven out of the past seven days. Review of the resident's care plans revealed there was no plan developed to address the use of an antidepressant medication. According to the Medication Administration Record [REDACTED]. However, there was no clinical record documentation from (MONTH) 9, (YEAR) through (MONTH) 6, 2019 that the resident had been monitored for any target behaviors related to depression, or that the resident was consistently monitored for adverse side effects related to an antidepressant medication. An interview was conducted on (MONTH) 7, 2019 at 9:24 a.m., with a Registered Nurse (RN/staff #104). She stated that when a resident receives an antidepressant, the nurse would be expected to verify an appropriate [DIAGNOSES REDACTED]. Staff #104 said the nurse would also be expected to monitor and document target behaviors related to antidepressant use each shift on the behavior sheets. She stated there was no behavior sheet or monitoring for resident #52, but there should have been since the resident was taking [MEDICATION NAME]. She stated the behavior sheets were normally initiated on admission and kept in the behavior binder, but she did not know the process for how the sheets were started and placed in the binder. An interview was conducted on (MONTH) 8, 2019 at 11:16 a.m., with the Director of Nursing (DON/staff #160). She stated it was the responsibility of the admitting nurse or the MDS coordinator to initiate behavior monitoring sheets and side effect monitoring sheets for residents taking antidepressants. She stated it was the responsibility of nurses who were administering antidepressant medications to monitor for and document the resident's target behaviors and side effects. She stated documentation should be done on the behavior and side effect sheets kept in the behavior binders on the units. She stated that there were no side effect monitoring sheets for resident #52 in the behavior binder, and they should have been there. She also said the facility did not have a policy for [MEDICAL CONDITION] medication administration, only a policy specifically for antipsychotic medication administration. | 2020-09-01 |