cms_VT: 13
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 |
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13 | MOUNTAIN VIEW CENTER GENESIS HEALTHCARE | 475012 | 9 HAYWOOD AVENUE | RUTLAND | VT | 5701 | 2019-02-14 | 842 | D | 0 | 1 | ZRVE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that medical records were complete and accurately documented for 2 of 30 residents in the sample (Resident #92 and Resident #114). Findings include: 1. Resident #92 was admitted to the facility on [DATE] with an indwelling catheter. Signed physician's orders [REDACTED].(milliliters) of N.S. (normal saline) twice a day. Per review of a nursing progress note dated 6/12/18, new orders were received for, [MEDICATION NAME] 2% urojet (pre-filled syringe with numbing medication)-squirt the 5 (milliliter) ml into urethra (duct by which urine is moved out of the body from the bladder) prior to foley re insertion with cath changes; [MEDICATION NAME] solution (irrigation solution) 30 ml-flush foley BID (twice a day) and PRN (as needed) foley clogging to maintain foley patency; d/c (discontinue) saline flushes. Per review of Resident #92's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for (MONTH) 2019, there was no evidence that these orders were being carried out to maintain Resident #92's catheter. Per interview on 2/12/19 at 3:31 PM with a staff nurse, s/he confirmed that there were no orders on the MAR and/or TAR for Resident #92's Foley catheter care. On 2/12/19 at 3:59 PM, during an interview with the Unit Manager, s/he also confirmed that there were no orders on the MAR and/or TAR for Resident #92's Foley catheter care. 2. Resident #114 was admitted to the facility on [DATE] with a Gastrostomy Tube ([DEVICE]). Signed Physicians orders from 1/15/19 read Glucerna (a high calorie nutrition) 1.2, special Instructions: H2O 160 ml (milliliters) flush with boluses, bolus amount (ml): 400, number of boluses/day: 3. On 1/16/2019, a clarification order was written for Glucerna 1.5 at 400 ml TID (three times a day) and signed by the Advanced Practice Registered Nurse (APRN). On 1/17/2019, another clarification order was written for Glucerna 1.5 @ 400 ml TID PT (per tube). The APRN signed and dated the clarification order on 1/21/19. Per review of resident #114's Enteral Protocol flow sheet (a form that the facility uses to document tube feeding administration) for the month of (MONTH) 2019, there was a hand-written entry for Glucerna 1.5 cal/ml (calorie per milliliter) 400 ml 4 times daily with the times documented as 0800, 1200, 1700 (only 3 times). There were 34 initialed opportunities to identify the incorrect documentation between 2/1/19- 2/12/19. On 2/12/19 at 3:30 PM during an interview with the Unit Manager, s/he confirmed that the monthly physician's orders [REDACTED]. S/he also confirmed that the hand-written Enteral Protocol flow sheet indicated that the Glucerna was to be administered 4 times a day, and that the documentation on the Enteral Protocol flow sheet was 3 times a day. | 2020-09-01 |