cms_RI: 9
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
9 | ROYAL OF WESTERLY NURSING CENTER | 415004 | 79 BEACH STREET | WESTERLY | RI | 2891 | 2019-08-08 | 759 | D | 1 | 1 | 02UK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on surveyor observations, record reviews, and staff interviews, it has been determined that the facility has failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 35 opportunities for error, there were five errors involving one resident (ID #6), resulting in an error rate of 14.29%. Findings are as follows: 1. Record review for Resident ID #6 revealed a [DATE] physician's orders [REDACTED]. During surveyor observation of the Medication Administration task on [DATE] at 7:38 AM, Staff Nurse C, prepared Aspirin chewable 81 mg instead of the delayed release/[MEDICATION NAME] coated Aspirin. 2. Record review for the resident revealed a [DATE] order with a stop date of [DATE] for [MEDICATION NAME] HFA aerosol inhaler (used to control and prevent symptoms of asthma). During surveyor observation on [DATE] at 7:38 AM, of the inhaler prior to administration, revealed an expiration date of (MONTH) (YEAR). Additionally, Staff C was observed administering the expired inhaler to the resident. 3. Record review for the resident revealed an [DATE] physician's orders [REDACTED]. Review of the Myrbetriq manufacturer's patient information states, in part, .Do not chew, break, or crush the tablet . During surveyor observation on [DATE] at 7:38 AM, revealed instructions on the pharmacy label stating, do not crush or chew. Additionally, Staff C was observed crushing the medication. 4. Record review for the resident revealed an [DATE] physician's orders [REDACTED]. Review of the Gericare [MEDICATION NAME] delayed-release manufacturer's directions on the original box state, in part, .swallow whole. Do not chew or crush capsule . During surveyor observation on [DATE] at 7:38 AM, Staff C cut open the [MEDICATION NAME] capsule, emptied the contents, and crushed the granules with the other medications. 5. Record review for the resident revealed a [DATE] physician's orders [REDACTED]. Review of the Vascepa manufacturer's prescribing information states, in part, .Patients should be advised to swallow Vascepa capsules whole. Do not break open, crush, dissolve or chew Vascepa . During surveyor observation on [DATE] at 7:38 AM, Staff C cut open the Vascepa capsule and emptied the liquid contents into the other medications. During an interview with Staff C, immediately after preparing the medications, she acknowledged that the medications were ready to be administered. She acknowledged the above errors and added that she must crush the medications for this resident. She proceeded to administer the medications to the resident after the errors were brought to her attention. During a subsequent interview on [DATE] at 9:32 AM, with the Director of Nursing Services, she was unable to provide evidence that the resident was free from medications errors. | 2020-09-01 |