cms_OR: 3
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3 | LAURELHURST VILLAGE | 385010 | 3060 SE STARK STREET | PORTLAND | OR | 97214 | 2019-02-27 | 580 | D | 1 | 1 | 71NL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to notify the physician for fluid overload and multiple missed medications and treatments for 1 of 1 sampled resident (#199) reviewed for death. This placed residents at risk for unmet medication and treatment needs. Findings include: Resident 199 was admitted to the facility in 9/2018, with [DIAGNOSES REDACTED]. On 10/25/18, Resident 199 was sent to the hospital and later passed away. Resident 199's 10/1/18 signed physician orders [REDACTED]. -[MEDICATION NAME] Solution 100 unit/ml (insulin) sliding scale subcutaneously with meals for diabetes; -Aspirin 81 mg every afternoon for heart health; -Nephro-Vit (B Complex-C-Folic Acid) tablet 1 mg every afternoon; -[MEDICATION NAME] (an antidepressant) 12.5 mg every morning for [MEDICAL CONDITION]; -[MEDICATION NAME] Solution 30ml TID for hepatic [MEDICAL CONDITION] (a decline in brain function due to liver disease); -Sevelamer (a [MEDICATION NAME] binder) HCL 800 mg TID with meals; -Fluid restriction 1000 ml-1200 ml/day every shift; and -Check CBG (capillary blood glucose) BID. Resident 199's 9/2018 and 10/2018 MARs and DARs (Diabetic Administration Record) documented the following number of missed medications as out of the facility: -[MEDICATION NAME] Solution: 9/2018 - 20 times and 10/2018 - 29 times; -Aspirin: 9/2018 - eight times and 10/2018 - 15 times; -Nephro-Vit: 9/2018 - eight times and 10/2018 - 15 times; -[MEDICATION NAME]: 9/2018 - eight times and 10/2018 - 9 times; -[MEDICATION NAME] Solution: 9/2018 - 16 times and 10/2018 - 23 times; -Sevelamer: 9/2018 - 16 times and 10/2018 - 26 times; and -Check CBG BID: 9/2018 - eight times and 10/2018 - 10 times. Resident 199's 9/2018 and 10/2018 TAR and Fluid Intake Flowsheet recorded 14 days where the resident was over her/his fluid intake of 1200 ml/day. There was no documented evidence in Resident 199's clinical record the resident's physician was notified regarding her/his multiple missed medications and treatments for fluid restriction and CBG checks. In an interview on 2/27/19 at 11:25 AM, Staff 11 (LPN) stated the resident was out of the facility due to [MEDICAL TREATMENT] and other activities. Staff 11 stated for certain medications like supplements she would give the resident's medication when she/he returned. Staff 11 stated it was difficult to monitor her/his fluid restriction but would notify the physician if the resident was going over her/his restriction and if she/he was consistently missing medications. In an interview on 2/27/19 at 12:38 PM, Staff 10 (Resident Care Manager-LPN) stated she expected nurses to check Resident 199's blood sugars and administer missed medication, if appropriate, when she/he left and returned to the facility. Staff 10 stated she expected nurses to notify the resident's physician for any missed medications and any fluid overload. In an interview on 2/27/19 at 1:32 PM, Staff 2 (DNS) was informed of the lack of notification to the resident's physician for missed medications and treatments. Staff 2 confirmed Resident 199's physician should have been notified for any fluid overload and missed medications and treatments. | 2020-09-01 |