cms_UT: 40
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 40 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 580 | E | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 4 of 43 sample residents, that the facility did not immediately inform the resident representative when there was a need to alter the resident's treatment and commence a new form of treatment. Specifically, one resident's physician was not notified of a change in condition, and three resident's physician's were not notified of medications that had not been administered nor of multiple medications that had not been given timely. Resident identifiers 4, 37, 163 and 170. Findings include: 1. Resident 170 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 170's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/12/18 New order by MD (Medical Doctor) for the patient: DC [MEDICATION NAME] Inhaler; amt (amount): 2 inhalations; Special Instructions: Dx (diagnoses) [MEDICAL CONDITIONS] Four Times A Day New order: Re-start on 1/16/2018 [MEDICATION NAME] inhaler; amt: 1 inhalations; Four Times A Day Increase monitoring for any respiratory issues. Notified (sic) to MD for any acute respiratory problem. Asses (sic) the patient every shift for respiratory problem. b. 1/28/18 at 21:30 (9:30 PM), (Recorded as Late Entry on 1/29/18 at 23:59 (11:14 PM), CNA (Certified Nursing Assistant) came to tell LN (Licensed Nurse) to come check on pt (patient) out of concern. LN went to observe pt. Called pt name and gently shook her shoulder, pt easily roused and responded. Ask how she was feeling and if she was in any pain, stated that she was just tired. Denies pain/discomfort at this time. Pt in no apparent distress. Pt was laying flat, LN raised HOB (head of bed) to semi fowlers. VS (vital signs) checked (Temperature) 98.2, (Pulse) 112, (Respirations) 14, (Blood Pressure) 96/62, (Oxygen Saturations) 92% 5L (liters) via NC (nasal cannula). Blood sugar 350. Lung sounds CTA (clear to auscultation) bilaterally. Respirations even and unlabored. Encouraged fluids. Pt checked and changed, barrier cream applied with brief change. Will notify MD. Nursing will continue to monitor. (NOTE: The nursing progress note did not explain what the concern was with resident 170 Additionally, the note was added to the medical record as a late entry after resident 170 had passed away.) c. 1/29/18 at 00:01 (12:01 AM), Went to check on pt, pt sleeping and easily roused. Responsive and able to respond appropriately to questions. Pt in no apparent distress and denies pain and/or SOB (shortness of breath). Respirations even and unlabored at 14, [MEDICAL CONDITION] (continuous positive air pressure) in place per orders while pt asleep. Nursing will continue to monitor. d. 1/29/18 at 3:02 AM, Checked on pt, still sleeping and easily roused. [MEDICAL CONDITION] in place and functioning. Woke her up and had her drink some water, responded and drank without any coughing or choking noted. CNA doing regular rounding and brief checks Q (every) 2 hours alternating with LN Q 2 hrs (hours). e. 1/29/18 at 5:00 AM, Pt check shows pt still sleeping in no apparent distress and easily woken. Cap (capillary) refill f. 1/29/18 at 5:30 AM, CNA was in room checking pt brief, LN joined to observe pt before the end of shift. Pt respirations even and unlabored. Pt in no apparent distress, skin pink warm and dry. [MEDICAL CONDITION] in place, pt responded to name and gentle shoulder shake. Denies pain, discomfort, or SOB. HOB elevated and RR 14. Encouraged pt to drink fluids throughout the day. Will report to oncoming nurse to monitor pt and encourage fluids throughout the day. g. 1/29/18 at 8:10 AM, Patient was find (sic) with respiratory distress, unresponsive with minimal arouse (sic), vitals was taking (sic) manually with no reading, patient with pulse 60 per min, respiration 24, laborated (sic) with O2 (oxygen) reading (saturations) 66 5 (66% on 5 liters of oxygen) in [MEDICAL CONDITION], interventions, change to face mask with 6 L oxygen, pull the head back to facilitated (sic) breading (sic) new O2 (saturation) 88%. Blood sugar check, blood sugar: 366 mg (milligrams)/dl (deciliter). Patient was able to open her eyes and was asked if she wanna (sic) go to ER (emergency room ), she state (sic) 'yes', 911 was called and MD notified. The vital sign report for resident 170 revealed that resident 170's vital signs were monitored and recorded as the following: a. 1/26/18 at 8:34 AM, Blood Pressure (BP) - 145/76, Pulse (P) - 78, Respirations (R) - 16, Temperature (T) - 97.8. O2 Saturation - 95% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air.) b. 1/27/18 at 9:57 AM, BP - 153/73, P - 83, R - 16, T - not taken, O2 Saturation - 90% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air.) c. 1/27/18 at 17:25 (5:25 PM), BP - 98/61, P - 68, R - 16, T - 97.9, O2 Saturation - 95% (NOTE: the report did not reveal if the oxygen saturation was with oxygen or on room air. Additionally, no documentation could be located in the medical record that resident 170's physician had been notified of the decrease in resident 170's BP and P, nor was there continued monitoring of the BP and P after they had decreased.) d. 1/28/18 at 9:03 AM, BP - not taken, P - not taken, R - 20, T - 97.8, O2 Saturation - 94% e. 1/29/18 at 10:07 AM, T - 97.9. (NOTE: It was unknown how this temperature was taken and documented as resident 170 had already been sent to the hospital in a nearly unresponsive state. Additionally, no vital signs could be located in the medical record consistent with the vital signs that were written in the late note on 1/29/18 at 11:14 PM.) No documentation could be located in the medical record to show resident 170's physician had been notified about the change in condition nor what the change in condition was. 2. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. physician's orders [REDACTED]. a. 10/18/17, [MEDICATION NAME]/[MEDICATION NAME] 2.5/0.05 Nebulizer every 8 hours. b. 12/1/16, [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) subcutaneous at Bedtime. c. 12/27/18 through 2/8/18, [MEDICATION NAME] 1 mg to 3.5 mg daily (QD). d. 7/17/18, [MEDICATION NAME] 70 mg weekly. e. 9/26/18, [MEDICATION NAME] 40 mg QD. f. 1/6/18, [MEDICATION NAME] 100 mg three times daily (TID). g. 1/2/18, [MEDICATION NAME] 2.5 mg QD. h. 10/9/17, [MEDICATION NAME] 20 mg QD. i. 1/11/18, Potassium Chloride 20 mEq twice daily (BID). j. 5/11/18, [MEDICATION NAME] 40 mg QD. k. 5/1/17, Sprionolactone 25 mg QD. l. 5/11/17, [MEDICATION NAME] 50 mcg QD. m. 12/12/18, [MEDICATION NAME] 200 mg at bedtime. n. 1/16/18 through 1/22/18, [MEDICATION NAME] 1 gram; intravenous (IV) once a day for UTI (Urinary Tract Infection). The Medication Administration Record [REDACTED] a. On 1/8/18 and 1/14/18 [MEDICATION NAME] 20 mg injection was not administered due to Drug/Item unavailable. b. On 1/16/18, [MEDICATION NAME] 1 gram IV was not administered to resident 37 due to waiting on med (medication) from pharmacy. c. On 3/10/18 [MEDICATION NAME] 100 mg was administered at 16:19 (4:19 PM), 2 hours and 19 minutes after it was due, due to Drug/Item unavailable. d. On 4/22/18 [MEDICATION NAME] 100 mg was Not Administered due to condition. e. On 4/22/18 [MEDICATION NAME] 3 mg was Not Administered, On Hold, Pt (patient) is very sleepy. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) resident 37 had multiple medications administered late including [MEDICATION NAME]/[MEDICATION NAME] TID, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 3 mg QD, [MEDICATION NAME] 70 mg weekly, [MEDICATION NAME] 40 mg QD, [MEDICATION NAME] 100 mg TID, [MEDICATION NAME] 2.5 mg QD, [MEDICATION NAME] 20 mg QD, Potassium Chloride 20 mEq BID, [MEDICATION NAME] 40 mg QD, [MEDICATION NAME] 25 mg QD, [MEDICATION NAME] 50 mcg QD and [MEDICATION NAME] 200 mg at bedtime No documentation could be located in resident 37's medical record to show that resident 37's physician had been notified of the medications that had not been administered nor of the late administration of resident 37's medications. 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 4's medical record was reviewed. physician's orders [REDACTED]. a. 4/17/17, [MEDICATION NAME] 325 mg 2 tablets TID. b. 8/15/18, [MEDICATION NAME] 10 mg QD. c. 4/18/17, Aspirin 81 mg QD. d. 8/15/17, [MEDICATION NAME] 5 mg at bedtime. e. 4/17/17, [MEDICATION NAME] 100 mg BID. f. 8/15/17, [MEDICATION NAME] 40 mg at bedtime. g. 1/30/17, [MEDICATION NAME] 10 mg QD. h. 4/17/18, [MEDICATION NAME] 10 mg QHS (bedtime) hold for systolic (blood pressure (BP)) i. 8/15/17, [MEDICATION NAME] 0.5 mg BID. j. 9/30/17, [MEDICATION NAME] 5 mg every six hours; at 2:00 AM, 8:00 AM, 2:00 PM and 8:00 PM, Hold if asleep. The MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) for resident 4 revealed the following: a. [MEDICATION NAME] 0.5 mg administered on 1/27/18 at 10:00 PM, 2/22/18 at 12:00 PM, 3/12/18 at 11:00 PM and 3/27/18 at 10:00 PM. Administration of the [MEDICATION NAME] 0.5 mg were administered two to four hours after they were due. b. [MEDICATION NAME] 0.5 mg was not administered on 2/28/18. c. [MEDICATION NAME] 5 mg administered on 3/24/18 at 10:00 PM, 4/7/18 at 12:00 AM, 4/10/18 at 9:30 AM and 4/23/18 at 4:45 AM. 3 administrations of the [MEDICATION NAME] 5 mg were administered 1 1/2 hours to 2 hours and 45 minutes after they were due. The administration of the [MEDICATION NAME] 5 mg at 12:00 AM was administered 2 hours before it was due. d. [MEDICATION NAME] 20 mg was administered on 1/11/18 with a BP of 108/70, 1/18/18 with a BP 112/57, 1/19/18 with a BP 132/56, 2/24/18 with a BP 109/56, 3/22/18 with a BP 120/51, 3/25/18 with a BP 112/58 d. [MEDICATION NAME] 5 mg was not administered on 1/12/18 at 2:00 PM, 1/14/18 at 8:00 PM, 1/16/18 at 2:00 PM, 2/22/18 at 8:00 AM, 2/22/18 at 2:00 PM, 3/8/18 at 8:00 AM, 4/10/18 at 2:00 PM. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), resident 4 had multiple medications administered late including [MEDICATION NAME] 325 mg TID, [MEDICATION NAME] 10 mg, Aspirin 81 mg daily, [MEDICATION NAME] 5 mg at bedtime, [MEDICATION NAME] 100 mg twice daily, [MEDICATION NAME] 40 mg at bedtime, [MEDICATION NAME] 10 mg daily, [MEDICATION NAME] 20 mg at bedtime, [MEDICATION NAME] 0.5 mg twice daily and [MEDICATION NAME] 5 mg every 6 hours No documentation could be located in resident 4's medical record to show that resident 4's physician had been notified of the medications that had not been administered nor of the late administration of resident 4's medications. 4. Resident 163 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 163's medical record was reviewed. physician's orders [REDACTED]. a. 10/30/17 through 11/9/[MEDICATION NAME] mg twice daily at 8:00 AM and 8:00 PM for UTI. b. 12/20/17 through 12/24/17 [MEDICATION NAME] 1.25 grams IV daily at 5:00 PM [MEDICAL CONDITION] Bacteremia. c. 10/13/17 Eliquis 5 mg twice a day at 8:00 AM and 8:00 PM for A-fib ([MEDICAL CONDITION]). The MAR for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following: a.[MEDICATION NAME] mg administered on 11/2/17 at 10:24 AM, 11/3/17 at 9:27 AM and 11/7/17 at 10:20 PM. Administration of [MEDICATION NAME] mg was 1 hour and 27 minutes to 2 hours and 24 minutes after they were due. b. [MEDICATION NAME] 1.25 grams IV administered on 12/20/17 at 7:23 PM. Administration of the [MEDICATION NAME] 1.25 grams was 2 hours and 23 minutes after it was due. c. Eliquis 5 mg not administered on 11/24/17 at 8:00 AM because med not avaialble(sic) notifeid (sic) pharmacy. No documentation could be located in resident 163's medical record to show that resident 163's physician had been notified of the late administration of resident 163's medications. On 4/30/18 at 10:30 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the physician should have been notified of the medications that had not been administered and and the late medications. On 4/30/18 at 4:30 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated I understand and see why there is a concern with this resident because of the lack of interventions. The facility DON acknowledged that there were no interventions of calling resident 170's physician, monitoring for the change in condition and no vital sign monitoring. Cross Refer to F-684, F-757 and F- 760 | 2020-09-01 |