cms_WY: 53
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
53 | SUBLETTE CENTER | 535017 | 333 N BRIDGER AVE | PINEDALE | WY | 82941 | 2017-02-02 | 514 | D | 0 | 1 | W1N011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of elimination protocol documentation, the facility failed to ensure the medical record was accurate and complete for 2 of 10 sample residents (#3, #35). The findings were: 1. During an interview on 2/2/17 at 9:15 AM the DON stated nursing staff should document interventions administered in accordance with the elimination protocol on the MAR. However, during an interview on 2/2/17 at 9:42 AM the medical records/CNA manager and DON stated nursing staff also documented on the elimination protocol sheets, which the DON kept in her office. She stated that information was not part of the medical record. 2. Review of the elimination protocol sheets and medical record for resident #3 for (MONTH) (YEAR) revealed the following: a. The resident was given [MEDICATION NAME] (stool softener), [MEDICATION NAME] (stool softener), and MOM (Milk of Magnesia - a laxative) on 1/5/17. Review of the MAR and nursing notes showed no documentation related to this. b. The resident was given [MEDICATION NAME], senna (laxative), and MOM on 1/9/17-1/10/17. Review of the MAR and nursing notes showed no documentation related to this. 3. Review of the elimination protocol sheets for (MONTH) (YEAR) showed resident #35 was administered senna on 1/10-1/11. Review of the MAR and nursing notes showed no documentation related to this. | 2020-09-01 |