cms_DE: 25
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
25 | KENTMERE REHABILITATION AND HEALTHCARE CENTER | 85001 | 1900 LOVERING AVENUE | WILMINGTON | DE | 19806 | 2018-12-06 | 758 | D | 1 | 1 | H65F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, it was determined that the facility failed to ensure medication regimens were free from unnecessary [MEDICAL CONDITION] medications for two (R15 and R83) out of 54 sampled residents. For R15, the facility failed to ensure that non-pharmacological interventions were used prior to her receiving PRN [MEDICATION NAME] and failed to monitor the effectiveness of her PRN [MEDICATION NAME]. For R83, the facility failed to limit PRN [MEDICAL CONDITION] medications to 14 days. Findings include: 1. Review of R15's clinical record revealed: 8/25/16- R15 was admitted to the facility and has [DIAGNOSES REDACTED]. 7/21/18- A recommendation from the pharmacist stated that R15 received [MEDICATION NAME] gel in July, but documentation whether it was effective or ineffective was inconsistent. A physician responded to the recommendation on 7/26/18 and stated, please have nursing document if effective or ineffective after administration. 9/25/18- R15 had a physician's orders [REDACTED]. 10/3/18 and 10/5/18- According to the MAR, R15 received [MEDICATION NAME] Gel on these dates. There was no documentation of non-pharmacological interventions used prior to administering the [MEDICATION NAME] and no documentation of the effectiveness of the medication, including in the progress notes and on behavior monitoring sheets. 10/28/18- R15 had a physician's orders [REDACTED]. 11/1/18, 11/6/18, 11/7/18, 11/11/18, 11/20/18, 11/23/18, 11/25/18, and 11/28/18- According to the MAR, R15 received [MEDICATION NAME] Gel on these dates. There was no documentation of the effectiveness of the [MEDICATION NAME] on all of the dates, including in the progress notes. Additionally, there was no evidence of non-pharmacological interventions being used prior to [MEDICATION NAME] administration on 11/1/18 and 11/28/18, including in the progress notes and behavior monitoring sheets. 12/5/18 2:35 PM- Findings were reviewed with E2 (DON). Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3, and E14 (QA). 2. Review of R83's clinical record revealed: 4/21/17 - R83 was admitted to the facility with [DIAGNOSES REDACTED]. 11/13/18 8:42 AM - A physician progress notes [REDACTED]. The plan was documented that R83 was to receive an order for [REDACTED]. 11/14/18 - An order was entered for R83 to receive [MEDICATION NAME] 0.25 mg PRN every 8 hours PRN for anxiety for 30 days. There was no documented rationale for ordering R83 [MEDICATION NAME] PRN for greater than 30 days. The facility failed to limit R83's PRN [MEDICATION NAME] to 14 days, or provide physician documented rationale. 12/5/18 4:30 PM - Findings were reviewed with E2 (DON). | 2020-09-01 |