cms_RI: 80
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
80 | OAK HILL HEALTH & REHABILITATION CENTER | 415027 | 544 PLEASANT STREET | PAWTUCKET | RI | 2860 | 2018-12-14 | 760 | E | 1 | 1 | BZ8811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, and staff interview, it has been determined that the facility has failed to ensure that residents are free of any significant medication errors for 1 of 5 sample residents receiving insulin for resident ID# 94. Findings are as follows: Record review for resident ID# 94 revealed a 11/18/2018 physician's orders [REDACTED]. Surveyor observation during the medication administration task on 12/13/2018 at approximately 8:35 AM revealed Staff Nurse B administered the Humalog to Resident ID# 94, despite a recorded blood sugar of 134 in the Medication Administration Record [REDACTED] Further review of the record revealed the following MAR indicated [REDACTED] -11/29/2018, 11:00 AM, blood sugar 130 -12/7/2018, 11:00 AM, blood sugar 93 -12/8/2018, 6:00 AM, blood sugar 149 -12/12/2018, 4:00 PM, blood sugar 129 During a surveyor interview immediately after the observation with Staff B, he was unable to explain why the insulin was administered when the blood sugar was below the parameters. The above medication errors involved 5 different nurses. During a subsequent interview with the Director of Nursing Services on 12/14/2018 at approximately 2:00 PM she was also was unable to explain why the insulin was administered when the blood sugar was below the parameters. | 2020-09-01 |