cms_NV: 62
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 62 | LEFA SERAN SNF | 295001 | 1ST AND A ST/ PO BOX 1510 | HAWTHORNE | NV | 89415 | 2019-10-16 | 756 | D | 0 | 1 | LI3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review and interview, the facility's attending physician failed to document a review and/or a course of action rationale of the monthly pharmacy medication regimens reviews for 2 of 12 sampled residents (Resident #7 and #14). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. A Pharmacist Progress Note dated 08/10/19, documented a recommendation to discontinue [MEDICATION NAME] and initiate [MEDICATION NAME] due to chronic use of [MEDICATION NAME] increasing the risk of infections. Resident #7's physician visit dated 09/13/19, documented the resident's medications were last reviewed 05/20/19. Resident #7's clinical record lacked documented evidence the facility's attending physician reviewed and/or acted upon the pharmacist's recommendations dated 08/10/19. On 10/16/19 at 11:51 AM, the Director of Nursing (DON) confirmed Resident #7's clinical record lacked documented evidence the attending physician documented a review and/or a course of action rationale for the monthly pharmacist medication regimen review dated 08/10/19. The DON confirmed the facility policy, requiring the attending physician to document a review of the monthly medication reviews, had not been followed. Resident #14 Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Pharmacist Progress Note dated 07/30/19, documented Resident #14 was taking [MEDICATION NAME] 150 microgram (mcg) daily for [MEDICAL CONDITION]. Most recent labs, dated 07/23/19, revealed low [MEDICAL CONDITION] Stimulating Hormone (TSH) (0.302, normal 0.340-4.820 milli-International units/milliliter (uiu/ml). The recommendation was to consider reducing [MEDICATION NAME] to 125mcg daily with a follow up TSH /Free T 4 test in six weeks. Resident had [MEDICATION NAME] 5 mg daily for [MEDICAL CONDITION] since 10/2018. Per GOLD (YEAR) guidelines (Global Initiative for [MEDICAL CONDITION]), oral glucocorticoids had no role in the chronic daily treatment in [MEDICAL CONDITION] due to the risk for systemic complications (bone loss, immunodeficiency, hypertension, fluid retention) combined with demonstrated lack of benefit in prevention of exacerbations. The recommendation was to slow taper [MEDICATION NAME] to prevent adrenal crisis. Would taper to [MEDICATION NAME] 2.5 mg daily for 1 month then discontinue. Resident #14's physician visit dated, 08/08/19, documented the resident's medications were reviewed on 08/30/18. Resident #14's Medication Administration Review (MAR) for (MONTH) and (MONTH) 2019, documented the Resident had been administered [MEDICATION NAME] 150 mcg one tablet by mouth every day and [MEDICATION NAME] tablet 5 mg by mouth daily. A Pharmacist Progress Note dated 08/27/19, documented Resident #14 was recently started on [MEDICATION NAME] 100 milligram every night at bedtime for pain. Care plan note dated 08/20/19, reported Resident #14 was experiencing increased sedation following initiation of [MEDICATION NAME]. Resident was currently receiving the lowest available dosage. The physician/nursing recommendation indicated to consider reevaluating risk versus benefit of continuing the medication. Resident #14's physician visit dated 09/13/19, documented the resident's medications were last reviewed 08/30/18. Resident #14's MAR for (MONTH) and (MONTH) 2019, documented the Resident had been administered [MEDICATION NAME] 100 mg every night at bedtime. Resident #14's clinical record lacked documented evidence the Resident's attending physician reviewed and/or acted upon the pharmacist's recommendations dated 07/30/19 and 08/27/19. On 10/16/19 at 11:55 AM, the DON confirmed Resident #14's clinical record lacked documented evidence the attending physician documented a review and/or a course of action taken for the monthly pharmacist medication regimen review dated 07/30/19 and 08/27/19. The facility policy titled, Drug Regimen Review, effective 04/01/03, documented it was the attending physician's responsibility to document a review of the pharmacist medication regimen review in the resident's clinical record. | 2020-09-01 |