cms_UT: 90
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 90 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 757 | G | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose, excessive duration, without adequate monitoring, or without adequate indication for its use. Specifically, 2 residents did not have adequate monitoring of PT/INR ([MEDICATION NAME] ratio/international normalized ratio) laboratory values. One resident was administered 2 additional doses of [MEDICATION NAME] after the INR was high. The findings for resident 15 were cited at a HARM level. Resident 143 was cited at a potential for harm. Resident identifiers: 15 and 143. Findings include: HARM 1. Resident 15 was admitted on [DATE], discharged on [DATE], readmitted on [DATE] and discharged on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. On 6/21/18, resident 15's medical record was reviewed. A care plan dated 3/13/18 and revised on 4/17/18 revealed a Focus of (Resident 15) has an alteration in hematological status. She is at risk for [MEDICAL CONDITION] related to epistaxis (nose bleed). (Resident 15) is also at risk for prolonged bleeding related to anticoagulant medication. Recent transfusion and alterations in labs. The goal developed was, (Resident 15) will remain free of complications related to altered hematological status through the review date. Some of the interventions developed revealed, Monitor/document/report PRN (as needed) following s/sx (signs and symptoms) of [MEDICAL CONDITION]:.low hgb/hct (hemoglobin/hematocrit). and Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Resident 15's History and Physical dated 5/16/18 revealed, CC (chief complaint)/Reason for admission: [MEDICAL CONDITION], hypovolemia. The laboratory values documented were hgb was 8.2 g/dL (grams per deciliter) which was low. The Hct was 27.4% which was low. (Note: There were no reference ranges documented on the History and Physical.) The Assessment and Plan revealed [MEDICAL CONDITION]: Hgb 8.2 on admission, stable from discharge and records from SNF (Skilled Nursing Facility). Resident 15's physician's orders [REDACTED]. a. 6/3/18, [MEDICATION NAME] Sodium Tablet Give 2.5 mg (milligrams) by mouth one time a day every Sun (Sunday), Tue (Tuesday) related to unspecified [MEDICAL CONDITION]. b. 6/2/18, [MEDICATION NAME] Sodium Tablet Give 5 mg by mouth one time a day every Mon (Monday), Wed (Wednesday), Thu (Thursday), Fri (Friday), Sat (Saturday) related to unspecified [MEDICAL CONDITION]. Nursing progress notes revealed the following: a. 6/1/18 at 8:05 PM, Pt (patient) readmitted to (name of nursing facility) from (name of hospital) following weight gain r/t (related to) [MEDICAL CONDITIONS] and [MEDICAL CONDITION].Pt has a bruise to her mid back, and some small bruises to bilateral arms. b. 6/4/18 at 4:08 PM, New order to draw PT/INR ([MEDICATION NAME] time/international normalized ratio) tomorrow r/t [MEDICATION NAME] use. c. 6/6/18 at 6:12 PM, Lab (Laboratory) results from 6/5: PT patient (sic) 42.8 (H) (high), INR 4.4 (H). Results faxed to MD (Medical Doctor) and left message with MD. Response pending. d. 6/7/18 at 1:24 PM, .Pt has had a bloody nose today likely r/t elevated INR. MD called again today about her INR level, with new orders to hold the [MEDICATION NAME] for 2 days and recheck PT/INR on 6/9/18. e. 6/7/18 at 3:06 PM, Pt's nose has continued bleeding despite clamp. MD called. Pt sent to hospital for cauterization or balloon placement. f. 6/7/18 at 5:28 PM, (Local Hospital) just called and stated pt's Hematocrit was low enough that she needed a blood transfusion, so they were sending her to (another hospital) for a blood transfusion, and also so she can get [MEDICAL TREATMENT] in the morning. MD notified. Resident 15's laboratory values completed on 6/5/18 at 6:23 PM were reviewed. Resident 15's PT was 42.8 seconds with a reference range of 8.8-11.5 seconds. Resident 15's INR was 4.4 with a reference range of 1.5-3.5. There was a written note signed by a nurse on the form that revealed, Faxed, noted (and) left message with MD 6/6/18 at 1810 (6:10 PM). An additional written note signed by a nurse with no date revealed, Hold [MEDICATION NAME] re(check) PT/INR (on) 6/9/18. Resident 15's (MONTH) (YEAR) Medication Administration Record [REDACTED]. (Note: Resident 15 had a PT/INR obtained on 6/5/18. The results were high and resident 15 was administered [MEDICATION NAME] on 6/5/18 and 6/6/18.) Resident 15's History and Physical from the hospital dated 6/7/18 revealed a chief complaint of low blood counts and need for [MEDICAL TREATMENT]. The History and Physical further revealed that .She presented to (local hospital) with a chief complaint of epistaxis. Which apparently has been happening now for the past 3-4 days. This apparently was successfully cauterized. Her INR is noted (sic) be approximately 7.8. For [DIAGNOSES REDACTED]. The History and Physical from the local hospital further revealed that resident 15's hgb was 6.0 g/dL which was a panic low with a reference range of 12.1 - 15.2 g/dL. Resident 15's Hct was 19.6 % which was a panic low with a reference range of 36.0 to 15.2%. Resident 15's PT was 72 seconds with a reference range of 9-12 seconds. Resident 15's INR was 7.7 which was a panic high with a reference range of .9-1.2. The Diagnosis, Assessment & Plan revealed 1. Acute blood loss [MEDICAL CONDITION] -will be tranfuse (sic) 1 unit PRBCs (packed red blood cells) now - will hold off on the 2nd unit PRBCs unless necessary. She will definitely need a 2nd unit of blood. But this can be given during [MEDICAL TREATMENT]. In addition, 5. Coagulopathy - INR currently is 7.7 - Will give vitamin K mg p.o (orally) (times) 1. (Note: Resident 15 was readmitted from the hospital on [DATE] with a hgb of 8.2 g/dL which was low and Hct was 27.4% which was low. Upon readmission to the hospital on [DATE] resident 15's Hgb was 6.0 g/dL panic low and Hct was 19.6% panic low. Resident was readmitted to the hospital and received PRBCs for the blood loss and Vitamin K for the high INR.) On 6/20/18 at 8:00 AM, the Director of Nursing (DON) was interviewed. The DON stated that the nursing staff obtained a physician's orders [REDACTED]. The DON stated that nursing staff obtained the blood sample in the early afternoon. The DON stated that [MEDICATION NAME] was administered during Flex hours in the evening with was between 3:00 PM and 7:00 PM. The DON stated that the [MEDICATION NAME] was administered as ordered until the laboratory results were returned and the physician provided new orders. On 6/20/18 at 10:55 AM, a follow up interview was conducted with the DON. The DON stated that she wanted to provide a Homelike environment for residents, so [MEDICATION NAME] was to be administered as ordered until the laboratory results were returned. The DON stated that PT/INR results may not be provided to the facility until the day after the blood sample was obtained. The DON stated that [MEDICATION NAME] was to be administered until the physician provided new orders. On 6/20/18 at 2:35 PM, a follow up interview was conducted with the DON. The DON stated that resident 15 did not have a reference range for the PT/INRs. The DON stated that she did not know why resident 15 received an additional 2 doses of [MEDICATION NAME] after the laboratory results revealed her PT/INR were high. The DON stated there was not a policy and procedure for [MEDICATION NAME] and PT/INR monitoring. On 6/20/18 at 9:18 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that nursing staff obtained blood samples prior to 2:00 PM and the local hospital laboratory picked up the samples around 2:00 PM. [MEDICATION NAME] doses were administered after dinner so the PT/INR results were returned prior to administering the evening dose of [MEDICATION NAME]. POTENTIAL FOR HARM 2. Resident 143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 143's medical record was reviewed on 6/21/18. Resident 143's Home Discharge - Physician Med (medication) Order dated 9/15/17 revealed to hold [MEDICATION NAME] 5 mg at night. The orders further revealed, INR in AM - on [MEDICATION NAME]. INR on 9/15 was 5.4. [MEDICATION NAME] on hold. In addition, the physician [MEDICATION NAME]([MEDICATION NAME]) 250 mg (1 tablet) po BID (twice daily) for 5 days. There were no INRs in resident 143's medical record for 9/16/17. The facility nursing staff filled out a physician referral form dated 9/19/17. The form revealed that a facility nurse documented, Resident Nurse Observations/Patient Complaints: very, very confused, confusion over hospital orders, need PT/INR drawn today! [MEDICATION NAME]? The Physician documented, [MEDICATION NAME] 2.5 mg M (Monday) W (Wednesday) F (Friday) (and) 5 mg other days. Recheck [MEDICATION NAME] on (sic) wk (week). The form further revealed, INR (equals) 1.4. Resident 143 had a physician's orders [REDACTED]. (Note: Resident 143 completed [MEDICATION NAME] ordered on [DATE]. Resident 143 was ordered a different antibiotic on 10/2/17.) The Nursing (YEAR) Drug Handbook stated that [MEDICATION NAME] and [MEDICATION NAME] medications both have a drug interaction warning with [MEDICATION NAME]. The warning revealed, (MONTH) increase anticoagulant effect. Monitor patient carefully for bleeding. Reduce anti coagulant dosage as directed. (YEAR) Wolters Kluwer. Nursing (YEAR) Drug Handbook. Philadelphia. page 1494. Resident 143's nurses notes revealed the following entries: a. 10/5/17 at 5:27 PM, Pt is alert and oriented x 2 today with confusion. Remains on ABX (antibiotic) for UTI without adverse reactions. HRR (heart rate reserve) lung sounds CTA (clear to auscultation) and bowel sounds active (times) 4.New orders.check PT/INR, CBC and CMP (comprehensive metabolic panel) today instead of tomorrow and abdominal ultrasound on 10/6/17 noted. Blood specimen collected from right hand and sent to lab for analysis. Resting quietly in bed at this time without s/sx (sign or symptoms) of pain or distress. Will continue to monitor. b. 10/5/17 at 11:59 PM, .Received a phone call from (local hospital) lab to (sic) critical results. INR 8.8, NA + (sodium) 120, K+ (potassium) 6.9. (Physician) on call for (Resident 143's physician) gave order to transport to hospital for evaluation and treatment. Daughter notified et (and) agreed with transport.(Local hospital) notified. Resident 143's laboratory results revealed the following: a. 9/27/17, PT was 20 which was high and INR was 2.0. b. 10/5/17 at 4:00 PM, the blood sample was collected. The laboratory received the blood sample at 10:30 PM. PT was 100.4 high and INR was 8.8 PH. The results were called to the facility nurse at 10:57 PM. (Note: According to the laboratory results form the reference range for PT was 8.8-11.5 seconds and the reference range for INR was 1.5-3.5.) A review of resident 143's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the resident 143's Emergency Provider Report dated 10/5/17 at 11:57 PM revealed, .Sodium 119 PL (panic low), Plasma Potassium 6.9 PH (panic high).INR (1.5 - 3.5) 10.5 PH. I discussed the case with the hospitalist (name of physician removed) and he accepted the patient for admission. Primary Impression: Altered mental status. Secondary Impressions: Coagulopathy, Dehydration, [MEDICAL CONDITIONS]. On 6/20/18 at 9:30 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that PT/INR laboratory draws were completed Monday through Friday and sent to the local hospital laboratory. LPN 1 stated that after a blood sample was obtained she tried to call the laboratory prior to administering [MEDICATION NAME] to obtain the PT/INR results. LPN 1 stated that after receiving the results she notified the physician and the physician provided new orders. LPN 1 stated that she called physicians multiple times with laboratory results. LPN 1 stated that if the physician did not respond timely then she called the facility Medical Director. LPN 1 stated that she was the nurse for resident 143 on 10/5/17. LPN 1 stated that she did not remember why she contacted the physician to obtained an order for [REDACTED]. LPN 1 stated that she did not administer the [MEDICATION NAME] the evening on 10/5/17. LPN 1 stated that the night nurse administered the [MEDICATION NAME]. On 6/20/18 at 2:35 PM, the Clinical Resource Nurse (CRN) was interviewed. The CRN stated that [MEDICATION NAME] was to be administered as normal until the results were returned and the physician provided new orders. The CRN stated that if a resident was on antibiotic, then she would have increased monitoring of sign and symptoms of bleeding. | 2020-09-01 |