cms_OR: 79
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 79 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 552 | G | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined the facility failed to ensure resident's be informed, participated in treatment and were treated with dignity and respect for 2 of 8 sampled resident (#s 4 and 24) reviewed for medications and dignity. This placed residents at risk for lack of dignity and Resident 4 experienced a symptomatic hypoglycemic (low blood sugar) episode with a low blood sugar level of 22. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A public complaint was received on [DATE] indicating Resident 4 was administered 70 units of [MEDICATION NAME] (a long-acting insulin used to lower blood sugars) despite the resident stating she/he was not receiving that dose in the hospital. This resulted in a low blood sugar and the resident was sent out to the hospital. A Situation, Background, Assessment or Appearance (SBAR) progress note dated [DATE] at 3:45 AM indicated the following: -At 5:05 AM Staff 30 (LPN) was called to the Resident 4's room. The resident's skin was cool to touch, sweaty and the resident had mild shaking. She checked the resident's blood sugar and the reading was 22. The note indicated Staff 30 consulted with another nurse and called the emergency department. -The emergency medical technicians (EMTs) arrived and checked the resident's blood sugar which was lower than their machine could read. The EMTs started an Intravenous (IV) [MEDICATION NAME] (a form of glucose injected into a vein through an IV to treat low blood sugar) and rechecked the blood sugar and indicated a reading of 118. At 5:50 AM Resident 4 exited the building. On [DATE] at 9:31 AM Resident 4 stated she/he admitted to the facility on [DATE] from the hospital. During her/his hospital stay she/he recalled being administered 30 units of [MEDICATION NAME] two times daily. The nurse came in to administer her/his insulin and indicated she/he would be given 70 units of [MEDICATION NAME]. The resident told the nurse this was not what she/he received in the hospital. The nurse stated this is what their order is and that is what will be given. The resident stated she/he woke up around 4:00 AM and was groggy, hot, sweaty and felt out of sorts, did not really know how she/he called for help, but did. The same nurse which administered the insulin came in and took her/his blood sugar, which was in the low 20s. The resident thought the paramedics arrived around 6:15 AM and her/his blood sugar was even lower. Resident 4 stated they transported her/him to the hospital. The resident requested not to return to the facility at the hospital and stated I could have died . On [DATE] at 10:28 AM Staff 30 (LPN) stated she recalled the resident and worked with her/him the night of [DATE]. She indicated she reviewed the medications in the system and administered the insulin per physician orders. When asked if the resident had concerns regarding the 70 units of insulin Staff 30 did not recall the resident having any issues or concerns regarding the dosage. She stated a CNA called her into the resident's room due to the resident reporting she/he felt shaky. She stated she took the resident's blood sugar and the reading was low, and then she contacted the paramedics. She could not recall anything else about the incident. On [DATE] at 11:34 AM Staff 11 (RNCM) stated if a resident was questioning her/his insulin dosage she would have expected Staff 30 (LPN) to not administer the medication and follow up on the concern. Staff 11 stated the residents voice trumped the administration of medication when in question. 2. Resident 24 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. A [DATE] CAA revealed Resident 24 received both scheduled and PRN pain medication. Resident 24 had frequent pain with a nine pain level from a scale of one to 10 with 10 the highest level of pain. Resident 24 had shortness of breath with exertion or lying flat. It was hard for Resident 24 to stay asleep and to complete day to day activities. A [DATE] physician signed Skilled Nursing Facility Transfer Orders instructed staff to administer 1 to 3 tablets of [MEDICATION NAME] (to relieve pain) every three hours PRN for pain. A [DATE] at 1:54 PM Nursing Note revealed Resident 24's pain continued to be addressed with her/his PRN pain medications. A ,[DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On [DATE] at 7:37 PM Staff 29 (LPN) stated to Resident 24 all of her/his [MEDICATION NAME] medications were discontinued. No documentation was found in the clinical record. Resident 24's [MEDICATION NAME] was discontinued. On [DATE] at 7:42 PM Staff 29's voice was raised and was heard two rooms down the hall from Resident 24's room. Staff 29 stated Resident 24 did not have an order for [REDACTED]. On [DATE] at 12:05 PM Resident 24 stated her/his pain was a seven out of 10 on [DATE] in the evening. Resident 24 stated Staff 29 was unprofessional and she/he went to Staff 2 (DNS) to complain. Resident 24 stated Staff 29 came back later on [DATE] and placed a cup with pills in it on her/his bedside table but she did not apologize. On [DATE] at 11:40 AM Staff 2 confirmed Staff 29 should have validated the medication and not argued with Resident 24. | 2020-09-01 |