cms_ID: 72
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 72 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2018-04-12 | 602 | D | 1 | 0 | 0IO011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and review of policies, clinical records, employee time records, and facility investigations, it was determined the facility failed to ensure 1 of 7 sampled residents (#9) was free from misappropriation of a controlled pain medication. This failed practice resulted in misappropriation of Resident #9's [MEDICATION NAME] by Staff #[NAME] It also created the potential for other residents to experience uncontrolled pain if misappropriation of their controlled pain medications was undetected. Findings include: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses, including end stage liver disease. A physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. Resident #9's (MONTH) (YEAR) MAR indicated [REDACTED]. There was no documentation that [MEDICATION NAME] was administered to Resident #9 in the (MONTH) (YEAR) MAR. There was no documentation in the progress notes, dated 11/7/17 through 11/30/17, that [MEDICATION NAME] was administered to Resident #9. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg were delivered to the facility. The narcotic count sheet documented Staff #A signed that she administered 15 of 16 doses between 11/14/17 and 11/20/17. One dose, dated 11/19/17 at 12:00 PM, documented different initials in the Administered By column, but was the same handwriting as Staff #A's in all the other documentation. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A signed that she administered 15 of 15 doses between 11/22/17 to 11/26/17. The narcotic count sheet documented 11 doses remained in the bubble pack card. An undated summary of the facility's investigation, signed by the Administrator, DNS, and ADON on 12/8/17, documented, On 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of the medication cards on (Resident #9's name) had medications taped back into the card. The investigation documented (Staff A's name) had signed out the medications to this resident and that the medications taped in did not correlate, in appearance, with what was described on the Pharmacy identification tag. The summary documented the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented Staff #A was not available for interview until 11/30/17 at 2:00 PM. Staff #A admitted to taking Resident #9's [MEDICATION NAME] and replacing the remaining 11 doses in the bubble pack card with [MEDICATION NAME]. The investigation documented Staff #A was taking the [MEDICATION NAME] from Resident #9 for personal use since the beginning of November. Staff #A was suspended pending investigation. The investigation summary documented, Per the results of this investigation we feel this was an isolated incident that began in the beginning of November, involved one resident, and did not result in bodily harm or any adverse effect to the identified resident or other residents. The identified nurse was suspended, reported to the nursing board, and local Police were notified . The investigation summary documented the Board of Nursing and the Police Department were both notified on 12/1/17, four days after the facility knew about the misappropriation of the controlled medication by Staff #[NAME] The Bureau of Facility Standards Long Term Care Reporting System documented the facility notified the State Survey Agency on 12/1/17 at 11:25 AM, four days after the facility knew about the misappropriation of the controlled medication by Staff #[NAME] On 4/11/18 at 1:00 PM, the facility provided a current employee job profile that listed Staff #A as an LPN. On 4/11/18 at 4:25 PM, the DNS stated Staff #A told him that she was in a program for recovering nurses. The DNS was unable to provide documentation about the recovering nurses program and was unaware of any restrictions or limitations for Staff #[NAME] The DNS stated Staff #A returned to work under his supervision and her job duties entailed filing paperwork. The DNS stated Staff #A was not working as a nurse, was not providing direct patient care, did not have access to the electronic medication records, and did not have keys to access the medication carts or medication rooms. On 4/12/18 at 8:30 AM, the Administrator stated the facility did not press charges against Staff #A with the police department. The Administrator stated he did not have a copy of the police report and it would take 3 business days to get a copy of the police report. On 4/12/18 at 10:00 AM, the DNS provided a Program For Recovering Nurses (PRN) contract for Staff #A dated 1/7/18. The PRN contract documented, I shall not return to work until I receive written approval from the PRN and support of my treatment provider. In the event that I change positions or seek new employment, I shall obtain approval from the PRN at least two weeks prior to accepting the position. To begin working, I must first have a work monitor in place and all releases must be signed for the hiring facility. The PRN contract was signed by Staff #A on 1/7/18 and a witness signed the contract five days later on 1/12/18. The DNS stated he did not have the PRN contract until 4/12/18 and he was unaware that written approval from the PRN program was required for Staff #A to return to work in any capacity. The DNS stated Staff #A filed paperwork in his office or the charge nurse room within the conference room and only worked when he was in the building. Staff #A's employee time record documented Staff #A worked 4-6 days per week between 2/12/18 to 4/9/18, including 3 Saturdays in (MONTH) (YEAR) (3/17/18, 3/24/18, and 3/31/18). On 4/12/18 at 10:30 AM, the DNS stated he was not aware Staff #A had worked on Saturdays. The DNS stated he was not in the building and Staff #A was not supervised on those dates. | 2020-09-01 |