cms_UT: 100
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 100 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2019-10-28 | 760 | G | 1 | 0 | KWP211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility did not ensure that 1 of 7 sample residents was free of significant medication errors. Specifically, a resident was given his roommate's medications, and was subsequently hospitalized . As of 10/27/19, the facility had identified the concern, and had implemented a Quality Assurance (QA) plan which included audits, monitoring, and preventative measures to prevent further incidences. Therefore, past non-compliance at a harm level was cited. Resident identifier: 1. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 10/28/19. A nurses' progress note on 10/20/19 at 10:56 PM documented .Resident was given [MEDICATION NAME] and [MEDICATION NAME] in error. Resident responsive to stimuli. Neuro (neurological) checks within normal limits. Another nurses' noted dated 10/21/19 at 3:32 AM documented (Resident 1) in 21-B, reports c/o (complaints of) SOB (shortness of breath) with rales and crackles. that began on 10/20/2019 2:30 AM and have gotten worse since the onset. NA (?) make the symptoms worse, while Oxygen 4L (liter) improve the symptoms. Other relevant information - Medication error at about 2000 (10:00 PM) .The relevant areas to the change in condition is: Respiratory Status Changes, Shortness of breath, Abnormal lung sounds, Labored breathing. Assessment : The current problem seems to be related to Cardiac, Respiratory, .Medication error. Recommendation: (name redacted) NP (nurse practitioner) was notified and made aware of the resident's current status. The following orders were received: hospitalization with emergency transport. A follow up nurses' note dated 10/21/19 at 7:35 AM documented REsident (sic) taken to the hospital at about 3:30 am by EMTs (emergency medical transport). Pt (patient) was stabilized on a [MEDICAL CONDITION] (bilevel positive airway pressure) breathing machine and began improving according to ER (emergency room ) nurse sho (sic) also expected his non-responsiveness will pass in the next 12 hours as the medication wears off. (Note: resident 1 was admitted to the local hospital and did not return to this facility.) A hospital progress note dated 10/21/19 at 3:25 AM, documented [AGE] year-old male brought in by EMS (emergency medical services) in severe respiratory distress. According to paramedics the patient allegedly was given his roommates medications by mistake. This happened between 7:00 p.m. and 11:00 p.m. last night. Apparently the year (sic) was recognized right away and they opted to just monitor the patient. Over the last several hours he has apparently had worsening trouble breathing and decreased mental status. Patient is apparently normally alert and talkative. He is a full code. When his breathing became worse and his oxygen saturations began to drop they contacted 911. By EMS arrival the patient was obtunded but breathing on his own. He was placed on [MEDICAL CONDITION] (continuous positive airway pressure) which he fought briefly and then tolerated. EMS states that he was not opening his eyes and was responding only to pain. Medications given in error were [MEDICATION NAME] 10 mg, [MEDICATION NAME] 200 mg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 100 mg. It also appears that he was given his usual evening medication including 10 mg of [MEDICATION NAME] 40 mg, and [MEDICATION NAME] 125 mg. A follow up hospital note from a re-evaluation on 10/21/19 at 4:45 AM, documented I discussed this case with poison Control. Based on the medication and amounts that patient received they estimated at least another 10-12 hours of sedation. They were not aware of any potentially useful reversal agents. Patient did have a gag reflex. He did respond to pain but not voice. Over the course of the 1st hour he stayed on [MEDICAL CONDITION] he was moaning more and becoming somewhat more responsive to pain. His ABG (arterial blood gases) done 1 hr after arrival showed PH of 7.33 with pCO2 of 46 and a PO2 of 133. His oxygen saturation remained at or above 97% on [MEDICAL CONDITION]. patient was switched to [MEDICAL CONDITION]. He tolerated this well. Patient was becoming more verbal and moving more. Vital signs remained within the normal range. The on-call respiratory tech is agreeable to staying in the hospital to monitor the patient. I will be available should his respiratory status decline. He will be admitted to our step-down ICU (intensive care unit), where he will be kept on [MEDICAL CONDITION] and monitored. A Quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] documented under section G, that resident 1 required limited assistance from 1 person for bed mobility, ambulation, and toilet use. Resident 1 was documented as needing extensive assistance of 1 person to transfer from bed, and needed set up and supervision assistance only for eating. A progress note from resident 1's new admitting facility, dated 10/23/19, documented (Resident 1's) current reason for skilled stay is lethargic and weak, confused, requires ext (extensive) assist with cares and staff to anticipate needs, requires assist with eating, nutrition and medication management. Alertness/Cognition/Orientation: responds to loud voice, able to answer simple questions appropriately, speech slurred, drowsy. The resident's functional status ability is: The resident is dependent with bed mobility; transfers did not occur; extensive assist with eating; dependent with toileting; walking did not occur; and locomotion did not occur. An addition progress note, dated 10/27/19, documented Resident in bed this morning during breakfast. He is a total feed. He doesn't attempt to do any help. Staff will attempt to get him out of bed for lunch and take him to the assist dine (sic). On 10/28/19 at 10:31 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that on 10/21/19 an agency nurse who was not familiar with the residents, was administering medications. The DON stated that the nurse went to administer resident 1's medications and got resident 1 mixed up with his roommate. The DON stated that the error was realized about 10 minutes later, the doctor was called and regular vital sign checks and monitoring was started. The DON stated that resident 1 started having a change in condition around 3:00 AM on 10/21/19, the nurse called the doctor, who ordered that the resident be sent to the ER. The DON stated that the facility had since started a 4 point process to correct medication errors. On 10/28/19 at 12:09 PM, a phone interview was conducted with resident 1's family member. The family member stated that resident 1 had not been out of bed, could not move his arms, and could not see as well since the medication error. The family member stated that prior to the medication error resident 1 was able to get up and feed himself which he could no longer do. On 10/28/19 at 1:30 PM, a phone interview was conducted with the Medical Doctor (MD) 1. MD 1 stated on 10/20/19 a nurse gave resident 1 his roommate's medications, which were mostly psychiatric medications. MD 1 stated that the combination of medications resident 1 received would definitely cause sedation and respiratory depression, especially since resident 1 did not usually take any similar medications. | 2020-09-01 |