cms_UT: 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 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 760 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that residents were not free of significant medication errors for 2 of 30 sample residents. Specifically, a licensed nurse administered prescribed medications to the wrong residents twice. Resident identifiers: 65 and 73. Findings include: 1. Resident 65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 65's medical record was reviewed on 1/11/18. Upon admission to the facility, orders were to administer the following medications to resident 65: a. [MEDICATION NAME] 100 mg (milligrams) daily; b. [MEDICATION NAME] 40 mg daily; c. [MEDICATION NAME] 60 mg daily; d. Vitamin D3 units daily; e. [MEDICATION NAME] 0.25 mg twice a day; and f. Potassium Chloride 30 meq (milliequivalents) twice a day; On 12/6/17 at 11:58 AM, Registered Nurse (RN) 2 documented in a progress note, Nurse came on shift with two new residents. One resident came to the nurses station and asked for her medications. Nurse asked for her name and resident did not reply. CNA (Certified Nurse Assistant) stated her name and nurse as resident 'are you _____?' resident replied yes. Res (Resident) was given wrong morning medications. Nurse assessed resident and her vitals are BP (blood pressure) 118/70 HR (heart rate) 71 Temp (temperature) 98.1 RR (respiration rate) 20. MD (Medical Doctor) assess Resident stated that resident was acting normal and that he had no issues or concerns. Approx. (approximately) 45 minutes after taking medications resident threw up. (Note: Resident 63 was given resident 73's ordered medications.) 2. Resident 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 73's medical record was reviewed on 1/11/18. Upon admission to the facility, orders were to administer the following medications to resident 73: a. Donepezil 10 mg daily; b. [MEDICATION NAME] 125 mcg (micrograms) daily; c. [MEDICATION NAME] 28 mg daily; d. Potassium Chloride 20 meq daily; and e. Apixaban 5 mg twice a day; On 12/6/17 at 12:01 AM, RN 2 documented in a progress note, Nurse came on shift with two new residents. Other Res (resident) was identified by CNA to nurse. Nurse asked for this residents name and resident did not reply. Nurse asked resident 'are you ______?' resident replied yes. Nurse checked for name band and none noted. Res was given wrong morning medications. Nurse assessed resident and her vitals are BP 129/76 HR 88 Temp 98.1 RR 16. MD Resident stated that resident was acting normal and that he had no issues or concerns. (Note: Resident 73 was given resident 65's ordered medications.) An interview was conducted with the Director of Nursing (DON) related to the medication errors. The DON stated that RN 2 worked once a week and was not familiar with resident 65 and 73. The DON stated that an investigation into the medication errors were conducted. The DON stated that RN 2 was educated related to to the 10 rights of medication administration. | 2020-09-01 |