| 36 |
THE MEADOWS ON UNIVERSITY |
355024 |
1315 S UNIVERSITY DR |
FARGO |
ND |
58103 |
2018-06-28 |
757 |
D |
1 |
1 |
ROZG11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to ensure each resident's medication regimen was free of unnecessary drugs for 1 of 14 sampled residents (Resident #9) identified as having severe/moderate pain. Failure to ensure adequate indications for increasing the dosage of the drug limited Resident #9's ability to reach or maintain her highest practicable mental, physical, and psychosocial well-being. Findings include: Observation on 06/25/18 at 3:22 p.m. and 06/26/18 at 4:22 p.m. showed Resident #9 sleeping in her bed. Observation on 06/27/18 at 11:15 a.m. showed resident sleeping in her wheelchair with her head down. Observation on 06/26/18 at 12:25 p.m., showed Resident #9 in the dining room slowly eating independently. The resident fell asleep numerous times throughout the meal. Observation on 06/27/18 at 8:37 a.m. and 06/27/18 at 12:31 p.m. showed the resident asleep with food in front of her at the dining table. Observation on 06/27/18 at 11:17 a.m., showed two certified nursing assistants (CNAs) (#10 and #11) attempted to wake Resident #9, who was asleep in her wheelchair in her room. The CNAs were unable to fully wake the resident. The resident did not open her eyes or lift her head. Resident #9 responded with groans when asked if she wanted to transfer to the toilet. A CNA (#10) stated, Recently, she is hard to wake up sometimes. If she does not wake up, instead of transferring her to the toilet, we check and change her in the bed. The CNAs transferred the resident to the bed and provided cares. The resident did not open her eyes or respond verbally while cares were done. The resident followed commands and groaned. Review of Resident #9's medical record on 06/27/18 showed a daily pain assessment documented as 0 for all of (MONTH) 1-31, (YEAR). Pain/Pain Assessment in Advanced Dementia Evaluation, entered on 05/09/18, indicated pain level of 0. The quarterly Minimum Data Set, dated dated [DATE], identified no presence of pain. A review of the physician's orders [REDACTED]. (was discontinued 05/16/18) . Increase [MEDICATION NAME] to 50 mg twice daily 5/16/18. Review of a progress note, dated 04/17/18, written by an activities staff member, stated . Care conf. (conference) held. (sic) in (Resident #9's) room. This writer present. (Resident #9) is alert, smiling and talkative through out. Dietary: 4/16 128.8# (pounds). Has had significant weight loss. Intakes vary on alertness, but recently downgraded to dysphagia mech. (mechanical) soft. Activities: Cont. (continue) to attend act. (activities) such as religious services, exercise, and socials. Often falls asleep requiring cues to stay awake and engage in activity. Nsg (nursing): A/O (alert/oriented) to self only. Vitals WNL (within normal limits). No pain issues. A provider note, dated 05/16/18, stated, (Resident #9) is a [AGE] year old female who is seen today at the request of staff for concerns of a rash on her lower legs and for increased pain, not controlled by her current regime. I do not see a rash on her lower legs. She does appear uncomfortable and I did increase [MEDICATION NAME] to 50 mg twice daily. In an interview on 06/28/18 at 1:41 p.m., an administrative nurse (#6) stated she could not find documentation of increased pain for Resident #9. |
2020-09-01 |