cms_ME: 14
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 14 | HIBBARD SKILLED NURSING & REHABILITATION CENTER | 205004 | 1037 WEST MAIN STREET | DOVER FOXCROFT | ME | 4426 | 2018-02-08 | 697 | E | 0 | 1 | RFBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility to document why pain medication was administered and/or failed to monitor and document the effectiveness of the pain medication for 4 of 6 residents reviewed for pain management (#65, #179, #180, #228). Findings: 1. On 2/6/18 at 10:09 a.m., in an interview with the surveyor, Resident #65 was showing physical signs of pain through facial grimacing and verbalizing pain. Resident #65 stated the pain is inside near his/her private area. Resident #65 stated to the surveyor that he/she told the nurse that he/she is experiencing pain. Documentation in the physician order [REDACTED].#65 had an order for [REDACTED].#65's Medication Administration Record [REDACTED]. On 2/6/18, at approximately 12:30 p.m., the resident was observed resting quietly in bed. On 2/8/18, a review of the MAR indicated [REDACTED] On 1/31/18 at 3:57 a.m., Resident #65 received Tylenol 650 mgs for the complaint of having pain at a 5-6 pain level. There was no evidence that the pain medication, Tylenol, was monitored for effectiveness after being administered. On 1/25/18 at 4:54 p.m., Resident #65 received Tylenol 650 mgs for the complaint of having pain at a 5-6 pain level. There was no evidence that the pain medication, Tylenol, was monitored for effectiveness after being administered. On 12/8/17 at 4:18 p.m., Resident #65 received Tylenol 650 mgs. There was no documentation as to why the Tylenol was administered. There was no evidence that the pain medication, Tylenol, was monitored for effectiveness after being administered. On 10/24/17 at 6:12 p.m., Resident #65 received Tylenol 650 mgs. There was no documentation as to why the Tylenol was administered. There was no evidence that the pain medication, Tylenol, was monitored for effectiveness after being administered. On 10/3/17 at 5:10 p.m., Resident #65 received Tylenol 650 mgs. There was no documentation as to why the Tylenol was administered. There was no evidence that the pain medication, Tylenol, was monitored for effectiveness after being administered. On 9/22/17 at 9:10 p.m., Resident #65 received Tylenol 650 mgs. There was no documentation as to why the Tylenol was administered. There was no evidence that the pain medication, Tylenol, was monitored for effectiveness after being administered. On 9/21/17 at 6:15 a.m., Resident #65 received Tylenol 650 mgs for the complaint of having pain at a 5-6 pain level for lower abdominal area. There was no evidence that the pain medication, Tylenol, was monitored for effectiveness after being administered. On 9/17/17 at 11:13 a.m., Resident #65 received Tylenol 650 mgs. There was no documentation as to why the Tylenol was administered. There was no evidence that the pain medication, Tylenol, was monitored for effectiveness after being administered. On 2/8/18 at 1:45 p.m., in an interview with the Long Term Care Unit Manager, the surveyor confirmed the above findings. 2. Resident #179 had physician orders [REDACTED]. On 1/30/18 at 9:00 p.m., Resident #179 received [MEDICATION NAME] two 325 mgs tablets for pain level of 7-8 intense, the clinical record lacks documentation of the effectiveness of this medication. On 1/31/18 at 3:53 p.m., Resident #179 received [MEDICATION NAME] 5 mgs for pain 9-10, the clinical record lacks documentation of the effectiveness of this medication. On 2/1/18 at 11:16 a.m., resident received [MEDICATION NAME] aerosol solution 2 puffs for shortness of breath (SOB), the clinical record lacks documentation of the effectiveness of this medication. On 2/2/18 at 1:31 p.m., the resident received [MEDICATION NAME] 5 mgs for general discomfort, the clinical record lacks documentation of the effectiveness of this medication. On 2/5/18 at 8:38 a.m., [MEDICATION NAME] 5 mgs for pain level of 10, clinical record lacks documentation of the effectiveness of this medication. At 12:27 p.m. second dose of [MEDICATION NAME] 5 mgs was given po for a pain level of 8, clinical record lacks documentation of the effectiveness of this medication. On 2/6/18 at 8:30 a.m. [MEDICATION NAME] 5 mgs was given for pain level of 8, clinical record lacks documentation of the effectiveness of this medication. A surveyor confirmed these findings with the skilled nurse manager on 2/8/18 at 1:00 p.m. 3. Resident #180 had Physician orders [REDACTED]. On 1/16/18 at 8:52 a.m. Tylenol Extra Strength 1000 mgs was given for pain level of 3, the clinical record lacks documentation of the effectiveness of this medication. On 1/19/18 at 10:07 a.m. [MEDICATION NAME] 4 mgs was given for pain level of 10, the clinical record lacks documentation of the effectiveness of this medication. On 1/20/18 at 7:42 a.m. [MEDICATION NAME] 4 mgs was given for pain level of 5-6, the clinical record lacks documentation of the effectiveness of this medication On 1/20/18 at 3:59 p.m. [MEDICATION NAME] 4 mgs was given for pain level of 5-6, the clinical record lacks documentation of the effectiveness of this medication On 1/22/18 at 8:38 p.m. [MEDICATION NAME] 4 mgs was given for pain level of 7-8, the clinical record lacks documentation of the effectiveness of this medication On 1/24/18 at 8:32 a.m. [MEDICATION NAME] 4 mgs was given for general discomfort, the clinical record lacks documentation of the effectiveness of this medication. On 1/26/18 at 12:59 p.m. [MEDICATION NAME] 4 mgs was given for pain level of 10, the clinical record lacks documentation of the effectiveness of this medication. On 1/26/18 at 9:42 p.m. [MEDICATION NAME] 4 mgs was given for general discomfort level of 8, the clinical record lacks documentation of the effectiveness of this medication On 1/27/18 at 8:42 a.m. [MEDICATION NAME] 4 mgs was given with no indication of pain level and the clinical record lacks documentation of the effectiveness of this medication. On 1/28/18 at 3:08 p.m. [MEDICATION NAME] 4 mgs was given for pain level of 8, the clinical record lacks documentation of the effectiveness of this medication On 1/31/18 at 3:12 p.m. [MEDICATION NAME] 4 mgs was given for pain level of 7-8, the clinical record lacks documentation of the effectiveness of this medication. On 2/1/18 at 8:35 p.m. [MEDICATION NAME] 4 mgs was given for general discomfort, the clinical record lacks documentation of the effectiveness of this medication On 2/2/18 at 2:35 p.m. and at 8:05 p.m. [MEDICATION NAME] 4 mgs was given for pain level of 10 and 7, the clinical record lacks documentation of the effectiveness of this medication On 2/4/18 at 12:03 a.m. [MEDICATION NAME] 4 mgs was given for pain level of 7, the clinical record lacks documentation of the effectiveness of this medication On 2/4/18 at 4:23 p.m. [MEDICATION NAME] 325 mgs was given for pain with no level indicated and the clinical record lacks documentation of the effectiveness of this medication. On 2/5/18 at 8:57 a.m. [MEDICATION NAME] 325 mgs was given for pain with no level indicated and the clinical record lacks documentation of the effectiveness of this medication. A Surveyor confirmed these findings with the Administrator on 2/8/18 at 4:22 p.m. 4. On 2/8/18 Resident #228's clinical record was reviewed. The clinical record contained an order, dated 2/1/18, for [MEDICATION NAME] 30 milligrams (mgs) every 4 hours as needed (PRN) for pain and an order for [REDACTED]. On 2/8/18 at 7:42 a.m., Resident #228's Electronic Medication Administration Record [REDACTED]. There was no documentation as to what the pain level was prior to the administration. In addition, the effectiveness was documented as effected at 7:42 a.m., immediately after administration. On 2/5/18 at 12:48 p.m., Resident #228's EMAR contained documentation that Resident #228 received [MEDICATION NAME] 30 mgs for general discomfort. There was no documentation as to what the pain level was prior to the administration. In addition, the effectiveness was documented as effective at 12:49 p.m., immediately after administration. On 2/8/18 at 1:15 p.m., during an interview with a surveyor, the Charge Nurse that administered both doses stated that he should have waited an hour before evaluating the Resident for effectiveness of the medication and he did not reassess the Resident. On 2/7/18 at 1:13 a.m., Resident #228's EMAR contained documentation that Resident #228 received [MEDICATION NAME] 30 mgs for pain at a level of 5-6, distressing all over. The clinical record lacked evidence of monitoring the effectiveness of this medication. On 2/6/18 at 8:07 p.m., Resident #228's EMAR contained documentation that Resident #228 received [MEDICATION NAME] 30 mgs for pain at a level of 5-6, distressing all over. The clinical record lacked evidence of monitoring the effectiveness of this medication. On 2/6/18 at 12:01 p.m., Resident #228's EMAR contained documentation that Resident #228 received [MEDICATION NAME] 30 mgs. The clinical record lacked evidence of why the medication was given and monitoring the effectiveness of this medication. On 2/5/18 at 10:12 p.m., Resident #228's EMAR contained documentation that Resident #228 received [MEDICATION NAME] 5 mg for pain. The clinical record lacked evidence of a pain assessment pain assessment prior to administration and monitoring the effectiveness of this medication. On 2/5/18 at 8:00 a.m., Resident #228's EMAR contained documentation that Resident #228 received [MEDICATION NAME] 5 mg for pain level of 10 in the back. The clinical record lacked evidence of monitoring the effectiveness of this medication. On 2/8/18 at 1:16 p.m., during an interview with the Administrator, the surveyor confirmed staff are not monitoring pain prior to administration of pain medication and/or monitoring for the effectiveness after administration of the pain medication. | 2020-09-01 |