| 10 |
SANTA FE CARE CENTER |
325030 |
635 HARKLE ROAD |
SANTA FE |
NM |
87505 |
2019-07-19 |
658 |
E |
0 |
1 |
W7WU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility staff failed to ensure [MEDICATION NAME] (a [MEDICATION NAME] supplement--live microorganisms that are intended to have health benefits) was given per physician orders [REDACTED].#8) of out of 14 ( R #2, R #11, R #13, R #15, R #33, R #35, R #43, R #48, R #63, R #70, R #96, R #300, and R #303) residents reviewed during medication pass. This deficient practice could result in the resident not receiving the desired therapeutic effect of the supplement. The findings are: [NAME] Record review of the physician orders [REDACTED]. B. Record review of the MAR (Medication Administration Record) for R #8 for (MONTH) 2019 revealed: [MEDICATION NAME] Capsule 250 mg (Saccharomyses boulardii) Give 2 capsules by mouth two times a day for gut health. The MAR showed that it was noted as being administered twice a day from 07/01/19 to 07/18/19 and once on 07/19/19. C. On 7/19/19 at 08:13 AM, during observation of the medication pass, RN #1 was observed removing 2 capsules from a bottle labeled acidophilus (a type of [MEDICATION NAME]--contains the bacteria Lactobacillus acidophilus) with pectin, ( fiber found in fruit used to make medicine) and administering them to R #8. D. On 7/19/19 at 3:15 am, during an interview, RN #1 confirmed that she had given R #8 2 capsules of acidophilus with pectin. RN #1 stated, Even though the MAR says to give [MEDICATION NAME] Capsules; we have never had the. We just give the acidopilus. It doesn't mean anything if the MAR and the medicine don't match in this instance, we all know it is the same thing ([MEDICATION NAME] and Acidophilus). E. On 07/19/19 at 10:00 am, during an interview, the ADON (Assistant Director of Nurses) stated, If the [MEDICATION NAME] was not available, the nurses should have contacted the doctor instead of giving the Acidophilus. It is not what was ordered. F. Review of the National Institute of Health, [MEDICATION NAME], Fact Sheet for Professionals, (MONTH) (YEAR), revealed: [MEDICATION NAME] exert their effects usually in the gastrointestinal tract, where they may influence the intestinal microbiota. [MEDICATION NAME] can transiently colonize the human gut mucosa in highly individualized patterns, depending on the baseline microbiota, [MEDICATION NAME] strain, and gastrointestinal tract region (4). [MEDICATION NAME] also exert health effects by nonspecific, species-specific, and strain-specific mechanisms (1). The nonspecific mechanisms vary widely among strains, species, or even genera of commonly used [MEDICATION NAME] supplements. Because effects of [MEDICATION NAME] can be specific to certain [MEDICATION NAME] species and strains, recommendations for their use in the clinic or in research studies need to be species and strain specific. |
2020-09-01 |