cms_RI: 27
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
27 | BRIARCLIFFE MANOR | 415012 | 49 OLD POCASSET ROAD | JOHNSTON | RI | 2919 | 2019-12-27 | 759 | D | 1 | 1 | IFE111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 30 opportunities for error, there were two errors involving two residents (ID #s 77 and 58) resulting in an error rate of 6.67%. Findings are as follows: 1. Record review revealed Resident ID #77 has a physician's orders [REDACTED]. Instructions on the card from the pharmacy indicate not to crush the medication. During the medication administration task on 12/19/2019 at 8:41 AM, Medication Technician, Staff A, was observed preparing Resident ID #77's medications, including the [MEDICATION NAME] ER, which she crushed and put into applesauce. The surveyor intervened prior to the administration of the medication when Staff A revealed that she was ready to administer the medication. During a surveyor interview with Staff A on 12/19/2019 at 8:48 AM, she acknowledged that she crushed the [MEDICATION NAME] ER and that the pharmacy instruction states that the medication should not be crushed. 2. Record review revealed Resident ID #58 has a physician's orders [REDACTED]. Instructions on the card from the pharmacy indicate not to crush the medication. During the medication administration task on 12/19/2019 at 9:08 AM, Medication Technician, Staff B, was observed preparing Resident ID #58's medications, including the [MEDICATION NAME] ER, which she crushed and put into applesauce. The surveyor intervened prior to the administration of the medication when Staff B revealed that she was ready to administer the medication. During a surveyor interview with Staff B on 12/19/2019 at 9:13 AM, she acknowledged that she crushed the [MEDICATION NAME] ER and that the pharmacy instruction states that the medication should not be crushed. On 12/19/2019 at 10:22 AM, the Director of Nursing Services was notified of the medication errors and revealed to the surveyor that she would expect that the Medication Technicians would not crush the [MEDICATION NAME] ER. | 2020-09-01 |