| 77 |
GATEWAY TRANSITIONAL CARE CENTER |
135011 |
527 MEMORIAL DRIVE |
POCATELLO |
ID |
83201 |
2018-04-12 |
684 |
D |
1 |
0 |
0IO011 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and review of policies, resident records, facility investigations, it was determined the facility failed to ensure professional standards of practice for medication management were followed for 3 of 9 sample residents (#3, #8, and #9) whose medications were reviewed. Resident #8 continued to receive an IV antibiotic after she may have experienced an allergic reaction to the medication. Resident #9's narcotic medication was discontinued and not destroyed in a timely manner, which contributed to the misappropriation of Resident #9's narcotic medication. Resident #3 did not receive ordered IV antibiotic medications, placing her at risk of ineffective antibiotic therapy. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/4/18, documented Resident #8 was cognitively intact and received IV antibiotics. a. Resident #8 began a six-week treatment of [REDACTED]. The facility continued to administer [MEDICATION NAME] to Resident #8 after she experienced possible signs and symptoms of an allergic reaction to the antibiotic as follows: The care plan addressing Resident #8's septic arthritis, dated 1/29/18, documented staff members were to obtain and monitor her lab work, as ordered, and report these results to the Infectious Disease (ID) physician. The care plan documented Resident #8 was on IV [MEDICATION NAME] for the infection. Physician orders [REDACTED].#8 received daily doses of IV [MEDICATION NAME], varying from 450 mg to 500 mg, [MEDICAL CONDITION]. Resident #8's MAR indicated [REDACTED]. During this period, Progress Notes included communication from the Nurse Practitioner (NP) to nursing staff, dated 2/20/18 at 10:30 AM, Resident #8 had a bilateral rash and swelling to her lower extremities that may be related to a possible reaction to [MEDICATION NAME]. The NP documented he would re-assess the rash after the [MEDICATION NAME] was discontinued and after Resident #8 finished a 5-day course of [MEDICATION NAME]. The NP did not suggest stopping the [MEDICATION NAME] at that time. The communication documented the NP also ordered as needed [MEDICATION NAME]. There was no documentation the NP nor facility staff notified the ID physician of Resident #8's 2/20/18 possible reaction to the [MEDICATION NAME]. A 2/21/18 Progress Note documented the NP evaluated Resident #8 and noted that she had a rash to lower extremities that might be reaction to an ABX (antibiotic). There was no documentation the facility reported the possible allergic reaction from the [MEDICATION NAME] to the ID physician at that time. A Progress Note, dated 3/2/18 at 5:20 AM, documented Resident #8 continued to receive [MEDICATION NAME] and continues to have a rash on legs and arms. Two Progress Notes, dated 3/2/18 at 11:10 AM and 3/5/18 at 12:22 PM, documented Resident #8 was administered 25 mg of as needed [MEDICATION NAME] for a rash and itchiness. There was no documentation the facility reported the possible allergic reaction from the [MEDICATION NAME] to the ID physician when signs and symptoms were identified on 3/2/18. A Progress Note, dated 3/6/18 at 2:03 PM, documented staff were to monitor Resident #8 for adverse side effects of [MEDICATION NAME] related to increased [MEDICAL CONDITION] (excess fluid buildup), rash, and pain every 8 hours for 72 hours and report the results to the physician. The note documented Resident #8 was sent to the emergency room for evaluation related to possible signs and symptoms of side effects to [MEDICATION NAME]. A Progress Note, dated 3/6/18 at 5:52 PM, documented Resident #8 had non-[MEDICAL CONDITION] located on her right arm and around the left side of her face. The note documented it was possibly related to [MEDICATION NAME]. The note documented Resident #8 had acute pain, a rash to all extremities, itching, and [MEDICAL CONDITION]. The note documented Resident #8 was admitted to the hospital for evaluation of the adverse reaction to the medication. A Progress Note, dated 3/6/18 at 5:57 PM, documented the facility notified the NP on 3/5/18 at 7:00 AM of a change in condition of new or worsening [MEDICAL CONDITION] to Resident #8. A 3/8/18 Progress Note documented the following communications between a nurse and the NP between 3/5/18 and 3/8/18. A summary of the LPN #1's communication on 3/5/18 at 1:31 PM, documented Resident #8 had a 6.4 critical lab value of potassium. A summary of LPN #1's communication on 3/5/18 at 3:28 PM, documented Resident #8 was having side effects from the [MEDICATION NAME] and the LPN was trying to contact the ID physician for instructions for what to do with the [MEDICATION NAME] order. A summary of LPN #1's communication on 3/5/18 at 4:23 PM, documented the ID physician's office was contacted about the signs and symptoms and they were relayed to the ID physician. The communication documented the office was under the impression the [MEDICATION NAME] was supposed to end on 3/2 but our orders end 3/6. A summary of LPN #1's communication on 3/5/18 at 4:24 PM, documented the ID physician agreed to hold the [MEDICATION NAME] and ordered [MEDICATION NAME] and [MEDICATION NAME]. A summary of LPN #1's communication on 3/6/18 at 7:01 PM, documented Resident #8's potassium level was elevated to 6.6. A summary of the NP's communication on 3/8/18 at 9:38 AM, thanked the LPN for the updates. On 4/12/18 at 5:35 PM, the ADON stated the facility called the NP when Resident #8 experienced signs and symptoms of a possible allergic reaction to the [MEDICATION NAME]. The ADON was unable to provide documentation the facility notified the ID physician who ordered the [MEDICATION NAME], or if the NP contacted the ID physician when Resident #8 experienced signs and symptoms of an allergic reaction to the [MEDICATION NAME] on 2/20/18 or 3/2/18. The ADON stated she would expect there to be communication between the provider or the facility if the resident was experiencing an allergic reaction from a prescribed medication. The ADON stated she would expect staff to stop the medication promptly and call the prescribing physician and wait for further instructions. The facility failed to report the signs and symptoms of possible allergic reaction to the ID physician who had been ordering and monitoring the [MEDICATION NAME]. Resident #8 was transported to the hospital to treat a critically high level of potassium and a possible signs and symptoms of an allergic reaction to [MEDICATION NAME]. b. Resident #8's interventions were not implemented fully after possible allergic reaction occurred on 2/20/18 as follows: Resident #8's Physician orders [REDACTED]. Resident #8's 2/20/18 through 2/26/18 MAR indicated [REDACTED]. Resident #8 missed two doses of the [MEDICATION NAME] on 2/21/18 and 2/25/18. The reason documented on 2/21/18 was documented as absent from the facility. Resident #8 was to receive the [MEDICATION NAME] at 7:00 AM in the morning, she was to receive 13 additional medications and/or treatments during that timeframe. The 2/21/18 MAR indicated [REDACTED]. The reason documented on 2/25/18 was Resident Spit out. There was no documentation the NP was notified that Resident #8 did not receive two doses of her [MEDICATION NAME] or that other attempts to administer the medication were attempted. Resident #8's Physician orders [REDACTED]. Resident #8's 2/20/18 through 3/6/18 MAR indicated [REDACTED]. On 4/12/18 at 5:35 PM, the ADON stated she would look into why the medications were not given. The facility did not provide information prior to exit of the survey. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/12/18, documented Resident #3 was cognitively intact and required extensive assistance of 1-2 staff members for cares. Resident #3's (MONTH) (YEAR) Physician orders [REDACTED]. Resident #3's 4/1/18 through 4/12/18 MAR indicated [REDACTED]. A Progress Note dated 4/11/18 at 10:48 AM, documented the reason for the missing dose was the medication was on order from the pharmacy. Resident #3's Pharmacy Delivery Records documented the facility received 3 doses of IV meropenem on 4/9/18, 4/10/18, and 4/11/18. On 4/12/18 at 2:03 PM, the ADON stated on 4/11/18 the facility was short staffed and had staff members call out sick. The ADON stated that she and three other nurses LPN #1, LPN #3, and LPN #4, covered the R-Hall medication cart on the morning of 4/11/18. The ADON stated the shift started with LPN #1 working the cart and the ADON relieved LPN #1. The ADON stated Resident #3's 6:00 AM meropenem dose was not administered and she did not know why, but was told the medication was not available. The ADON stated LPN #3 relieved her and then LPN #4 relieved LPN #3. The ADON stated Resident #3 received 2 of 3 doses of meropenem on 4/11/18 like the MAR indicated [REDACTED]. On 4/12/18 at 2:20 PM, the ADON was observed locating 3 IV bags of meropenem dated 4/12/18 with Resident #3's name on it. The ADON stated she did not open the refrigerator on 4/11/18 in the morning to check for the meropenem. On 4/12/18 at 2:30 PM, LPN #1 stated he could not locate Resident #3's IV meropenem in the refrigerator on 4/11/18 at 6:00 AM. He stated he called the physician and wait for further instructions. LPN #1 stated the physician did not call back on 4/11/18. LPN #1 stated the ADON and DNS instructed him to waited until the medication was located until providing the medication to the resident. On 4/12/18 at 2:33 PM, LPN #4 stated LPN #3 asked her to please administer Resident #3's 2:00 PM IV meropenem on 4/11/18. LPN #4 stated she located the IV meropenem in the refrigerator on 4/11/18, and she did not recall how many bags were in the refrigerator. LPN #4 stated she administered the 2:00 PM dose of meropenem. On 4/12/18 at 3:03 PM, LPN #3 stated on 4/11/18 around 2:00 PM, she located Resident #3's IV meropenem in the medication refrigerator and asked LPN #4 to please administer the medication. LPN #3 did not recall how many IV bags were in the refrigerator on 4/11/18. LPN #3 stated she did not recall pharmacy delivering any meropenem that morning or not. LPN #3 stated when she looked in the refrigerator the meropenem was there. On 4/12/18 at 6:25 PM, the DNS stated if an IV antibiotic dose was missed the nurse would call the physician for orders. The DNS stated if the physician added orders the nurse would call the pharmacy and the pharmacy would mix the medication and deliver the medication. The DNS stated he would expect the nurse to document the conversation. 3. According to the Drug Enforcement Agency Disposal of Controlled Substances Act, dated 9/9/14, Long-Term Care Facilities (LTCF) are required to dispose of controlled substances immediately, and no longer than three business days after the discontinuation of use by the LTCF resident. The facility's Narcotic Destruction Policy, dated 4/12/18, documented when a narcotic medication was needing to be wasted a witness would be present. The policy did not define when narcotics were to be disposed of. The policy was not signed off as reviewed by the medical director. Resident #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 3/26/18, documented Resident #9 was cognitively intact and exhibited no pain. Resident #9's (MONTH) (YEAR) MAR indicated [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. A physician's orders [REDACTED].#9's [MEDICATION NAME] 10 mg as needed was discontinued. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg. The narcotic count sheet documented Staff #A signed that she administered 16 of 16 doses between 11/14/17 and 11/20/17, before the [MEDICATION NAME] was discontinued on 11/21/17. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A continued to sign that she administered 15 of 15 doses between 11/22/17 to 11/26/17. Resident #9's narcotic count sheet for [MEDICATION NAME] documented 11 doses remaining 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 that on 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of Resident #9's medication cards had, medications taped back into the card. The DNS identified Staff #A was the only nurse signing the narcotic count sheet for Resident #9 and discovered the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented that Staff #A was interviewed on 11/30/17 at 2:00 PM, at which time Staff #A admitted to taking Resident #9's [MEDICATION NAME] and replaced 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 facility began the destruction process 6 days after the [MEDICATION NAME] was discontinued by the physician. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 2/12/18, documented Resident #3 was cognitively intact and required extensive assistance of 1-2 staff members for cares. Resident #3's (MONTH) (YEAR) Physician orders [REDACTED]. Resident #3's 4/1/18 through 4/12/18 MAR indicated [REDACTED]. A Progress Note dated 4/11/18 at 10:48 AM, documented the reason for the missing dose was the medication was on order from the pharmacy. Resident #3's Pharmacy Delivery Records documented the facility received 3 doses of IV meropenem on 4/9/18, 4/10/18, and 4/11/18. On 4/12/18 at 2:03 PM, the ADON stated on 4/11/18 the facility was short staffed and had staff members call out sick. The ADON stated that she and three other nurses LPN #1, LPN #3, and LPN #4, covered the R-Hall medication cart on the morning of 4/11/18. The ADON stated the shift started with LPN #1 working the cart and the ADON relieved LPN #1. The ADON stated Resident #3's 6:00 AM meropenem dose was not administered and she did not know why, but was told the medication was not available. The ADON stated LPN #3 relieved her and then LPN #4 relieved LPN #3. The ADON stated Resident #3 received 2 of 3 doses of meropenem on 4/11/18 like the MAR indicated [REDACTED]. On 4/12/18 at 2:20 PM, the ADON was observed locating 3 IV bags of meropenem dated 4/12/18 with Resident #3's name on it. The ADON stated she did not open the refrigerator on 4/11/18 in the morning to check for the meropenem. On 4/12/18 at 2:30 PM, LPN #1 stated he could not locate Resident #3's IV meropenem in the refrigerator on 4/11/18 at 6:00 AM. He stated he called the physician and wait for further instructions. LPN #1 stated the physician did not call back on 4/11/18. LPN #1 stated the ADON and DNS instructed him to waited until the medication was located until providing the medication to the resident. On 4/12/18 at 2:33 PM, LPN #4 stated LPN #3 asked her to please administer Resident #3's 2:00 PM IV meropenem on 4/11/18. LPN #4 stated she located the IV meropenem in the refrigerator on 4/11/18, and she did not recall how many bags were in the refrigerator. LPN #4 stated she administered the 2:00 PM dose of meropenem. On 4/12/18 at 3:03 PM, LPN #3 stated on 4/11/18 around 2:00 PM, she located Resident #3's IV meropenem in the medication refrigerator and asked LPN #4 to please administer the medication. LPN #3 did not recall how many IV bags were in the refrigerator on 4/11/18. LPN #3 stated she did not recall pharmacy delivering any meropenem that morning or not. LPN #3 stated when she looked in the refrigerator the meropenem was there. On 4/12/18 at 6:25 PM, the DNS stated if an IV antibiotic dose was missed the nurse would call the physician for orders. The DNS stated if the physician added orders the nurse would call the pharmacy and the pharmacy would mix the medication and deliver the medication. The DNS stated he would expect the nurse to document the conversation. 3. According to the Drug Enforcement Agency Disposal of Controlled Substances Act, dated 9/9/14, Long-Term Care Facilities (LTCF) are required to dispose of controlled substances immediately, and no longer than three business days after the discontinuation of use by the LTCF resident. The facility's Narcotic Destruction Policy, dated 4/12/18, documented when a narcotic medication was needing to be wasted a witness would be present. The policy did not define when narcotics were to be disposed of. The policy was not signed off as reviewed by the medical director. Resident #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 3/26/18, documented Resident #9 was cognitively intact and exhibited no pain. Resident #9's (MONTH) (YEAR) MAR indicated [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. A physician's orders [REDACTED].#9's [MEDICATION NAME] 10 mg as needed was discontinued. Resident #9's narcotic count sheet, dated 11/14/17, documented 42 doses of [MEDICATION NAME] 10 mg. The narcotic count sheet documented Staff #A signed that she administered 16 of 16 doses between 11/14/17 and 11/20/17, before the [MEDICATION NAME] was discontinued on 11/21/17. After the [MEDICATION NAME] was discontinued on 11/21/17, Staff #A continued to sign that she administered 15 of 15 doses between 11/22/17 to 11/26/17. Resident #9's narcotic count sheet for [MEDICATION NAME] documented 11 doses remaining 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 that on 11/27/17 it was reported to the DNS that during an attempt to waste a discontinued narcotic, one of Resident #9's medication cards had, medications taped back into the card. The DNS identified Staff #A was the only nurse signing the narcotic count sheet for Resident #9 and discovered the remaining 11 doses in the bubble pack card were [MEDICATION NAME], not [MEDICATION NAME]. The investigation summary documented that Staff #A was interviewed on 11/30/17 at 2:00 PM, at which time Staff #A admitted to taking Resident #9's [MEDICATION NAME] and replaced 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 facility began the destruction process 6 days after the [MEDICATION NAME] was discontinued by the physician. |
2020-09-01 |