| 12 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2018-05-17 |
658 |
D |
0 |
1 |
FGZ511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to meet professional standards of quality, by administering the wrong medication to the wrong resident, and failed to follow the 5 rights when administering medications to 2 (#s 19 and 35) of 37 sampled and supplemental residents. Findings include: During an observation and interview on 5/17/18 at 11:41 a.m., staff member B crushed a Tylenol 500 mg tablet at the medication cart for resident #19. Staff member B was observed looking at the MAR for resident #35. Resident #35's MAR indicated [REDACTED]. Staff member B stated resident #19 did not resemble the picture on the MAR indicated [REDACTED]. Staff member B stated, I know, (resident #19) used to look different as the staff member pointed to resident #35's picture. Staff member B walked away from the medication cart, and walked towards resident #19 with the crushed medication mixed in a tablespoon of ice cream. During an observation 5/17/18 at 11:43 a.m., staff member B administered the crushed Tylenol to resident #19. The resident stated she did not like the Tylenol with ice cream, and the resident made a grimacing face, and stated, It's not good. Staff member B stated, its ok, and continued spoon feeding resident #19 the crushed Tylenol. A review of resident #19's Annual MDS, with an ARD of 2/19/18, showed the resident had a BIMS of 9; moderate impairment. Her weight was 82 pounds. A review of resident #19's (MONTH) (YEAR) Medication Administration Record [REDACTED] a. [MEDICATION NAME] 650 mg suppository rectally every 4 hours if needed for fever or mild pain. b. [MEDICATION NAME] 325 mg take 2 tablets by mouth every 4 hours if needed for fever or mild pain. A review of resident #35's Annual MDS, with an ARD of 12/11/17, lacked a BIMS assessment. Her weight was 147 pounds. A review of resident #35's (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview on 5/17/18 at 11:52 a.m., staff member K stated resident #19 was seated in the dining room, and pointed to the table where resident #19 sat. Staff member K stated resident #35 was still in her room, on the other side of the MCU, and not in the dining room. During an interview on 5/17/18 at 12:13 p.m., staff member B stated she had given resident #19 medications prescribed for resident #35. Staff member B stated she had been oriented to the MCU by another staff member that was currently on vacation. Staff member B stated she was not familiar with all of the residents on the MCU, and had thought resident #19 was resident #35. Staff member B stated she was the only staff member in the MCU passing medications that day, and she was still learning which resident was which. Staff member B stated she should have ensured the 5 medication rights prior to administering medications to resident #19; the right patient, the right drug, the right dose, the right route, and the right time. Review of the facility's document titled, Skills- Medication Administration: Oral, read, 3. Verify the correct patient (sic) using two identifiers. References: http://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdministration.aspx One of the recommendations to reduce medication errors and harm is to use the 'five rights': the right patient, the right drug, the right dose, the right route, and the right time. |
2020-09-01 |