F332

Based on observation, interview, and record review, the facility failed to ensure two of three unsampled residents received their medications as ordered by the physician during the medication pass observation. (Resident 68 and Resident 23). This facility failure increased the potential for serious harm to residents who received discontinued medications and residents with missed medications that were not administered as ordered by the physician, In addition, this facility failure increased the potential for residents to experience medical complications [REDACTED]. During the facility medication pass reconciliation on February 15, 2016, the following was identified: 1. Resident 68 received a discontinued medication ([MEDICATION NAME]); 2. …

Riverside Postacute Care · California

This citation pertains to intake MI 006 Based on observation, interview and record review, the facility failed to maintain a medication pass error rate rate less than 5% (five percent) in 3 of 5 sampled residents (Resident #101, #102, & #104,) reviewed for medication administration, from a total sample of 5 residents, resulting in the potential for reduced medication effectiveness and increased risk of adverse reactions and or side effects. Findings include: Review of a Facility Policy dated 10/95 with a revision date of 5/15 and labeled Medication Administration revealed : Medications are prepared, administered, as prescribed, in accordance with good nursing principles and practices and only be persons legally authorized to do so. …

Medilodge of Zeeland · Michigan

The facility census totaled 55 residents and medication observation included 27 opportunities for error. Based on observation, interview and record review the facility failed to ensure staff administered medications correctly to ensure a medication error rate of less than 5% which involved insulin administration for 2 residents (#8 and #61) and omission of 3 medications for resident #56 with a total of 5 errors out of 27 opportunities for a rate of 18.5%. The facility also failed to ensure staff did not give resident #55 medications without orders and which were intended for another resident. Findings included: - Review of the physician's orders [REDACTED]. Observation on 11/14/17 at 11:03 a.m. revealed licensed nurse K removed a Humalog KwikPen from the medication cart. …

Diversicare of Larned · Kansas

Based on surveyor review of clinical records and interview of facility staff, it was determined that the facility staff failed to prevent a medication error rate of greater that 5%. This finding was evident in 2 of 27 residents observed during medication pass equaling a 7% med error rate. (#89, #1) The findings included: 1. On 08-28-17 at 7:05 PM, during medication administration observation on the Potomac unit, revealed the facility's Certified Medication Aide CMA) #7, administer [MEDICATION NAME] (a medication that treats digestive disease in which stomach acid or bile irritates the food pipe lining) 40 milligram (mg) by mouth to resident #89. Surveyor review of resident #89's clinical record revealed a physician's orders [REDACTED]. …

Autumn Lake Healthcare at Arcola · Maryland