of F333 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F333 is cited
0.0% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D133.3%
E266.7%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F333 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F333 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedDecember 5, 2017
Based on review of facility policy, review of facility contract, review of the Practical Nurse Program code of conduct, medical record review and interviews, the facility failed to prevent significant medication errors for 3 residents (#1, #4, #11) of 15 residents reviewed for medication errors. Resident #1 received 9 medications in error prescribed for Resident #2. The error resulted in Resident #1 becoming sedated, having decreased respirations, requiring multiple doses of [MEDICATION NAME] (medication used to treat an overdose of opioids in an emergency situation). …
Based on interview and document review, the facility failed to prevent a significant medication error for 1 of 4 residents reviewed, R1, when a staff person administered another resident's medication to R1. R1 experienced adverse symptoms due to the medication error, which required evaluation in the emergency department (ED) and inpatient monitoring.
R1's care plan, dated (MONTH) 15, (YEAR), indicated R1 had an alteration in vision. The care plan specified a goal to maintain safety, including administering medications as ordered and observing for side effects and effectiveness.
Review of the facility's schedules, dated (MONTH) 31, (YEAR) and (MONTH) 1, (YEAR), indicated Registered Nurse (RN)-D worked from 11 p.m. to 7 a.m. …
D · No harm, potential for more than minimal, isolatedAugust 8, 2018
Based on interview and record review, the facility did not ensure Resident A was administered the right medication per physician's orders.
Failure to follow physician orders and failure to administer the correct medication may potentially jeopardized Resident A's health and safety.
Findings:
Resident A was admitted to the facility 9/26/17 with [DIAGNOSES REDACTED].
Review of Physician Orders dated 9/28/17 (no time noted) indicated the following: Start 1 liter of 1/2 NS (Normal Saline) at 50 mg/hr (milligram per hour) for low BP (Blood Pressure) x 1 dose. On 9/28/17 at 0800 the order read, Start NS at 50ml/hr for 72 hours (3 days) and re-evaluate. On 9/30/17 the order read, Continue IV fluids through Monday (no date specified). …
B · No harm, potential for minimal, patternNovember 10, 2016
Based on observation, interview, and record review the facility failed to follow physician's medication orders and the facility policy for administering medications during the regular scheduled medication times of an hour before or an hour after 6:00 AM and 6:30 AM. This failure had the potential for the residents health to be compromised.
Findings:
During a concurrent medication observation pass and interview, on November 8, 2016, at 5:05 AM, Licensed Vocational Nurse (LVN 2) stated she had completed her morning medication pass for all her residents, except for one pill and one blood sugar check for one resident. …
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