Brookhaven at Lexington

In the surveyor’s words

From the most serious findings on record at Brookhaven at Lexington, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF656Oct 22, 2024

  Based on observation, record review, and interview, the facility failed for one Resident (#5) to follow the physician's order to obtain an apical pulse prior to administering the heart medication Digoxin, out of a total sample of ten residents. Findings include: Resident #5 was admitted to the facility in March 2018 and has active diagnoses which include heart failure, atrial fibrillation, seizures, and stroke. Review of Resident #5's most recent Minimum Data Set assessment, dated 9/3/24, indicated a Brief Interview for Mental Status exam score of 5 out of a possible 15, indicating severe cognitive impairment. Review of Resident #5's current physician orders indicated the following order: - Digoxin, 125 mcg (0.125 mg) tablet. Give 1 tablet by oral route once daily. […]

• No harm, potential for more than minimal, isolatedF658Oct 22, 2024

  Based on observation, record review and interview, the facility failed for one Resident (#5), to follow the professional standard for monitoring heart rate by apical pulse prior to administering the heart medication Digoxin, out of a total sample of ten residents. Findings include: Review of the [NAME] Drug Guide, 19th edition, 2024, indicated: - Monitor apical pulse for one full minute before administering oral Digoxin. Hold dose and notify health care professional if pulse rate is less than 60 beats per minute in an adult. The apical pulse is a pulse point located on the chest at the bottom tip (apex) of the heart. A stethoscope is used to hear the arterial pulse rate as the heart contracts and pumps out blood. […]

• No harm, potential for more than minimal, isolatedF761Oct 22, 2024

  Based on observation and interview, the facility failed to secure medications left on top of the medication cart during the medication pass. Findings include: On 10/22/24 at 9:51 A.M., during a medication pass with Nurse #1, the surveyor observed a small pink pill in a medication cup, located on top of the medication cart. Between 9:51 A.M. and 10:11 A.M., Nurse #1 left this medication unattended at various times, including while she was in a resident's bedroom administering medications. On 10/22/24 at 10:01 A.M., during a medication pass with Nurse #1, the surveyor observed Nurse #1 pour medications for a resident and place one tablet of Carbamazepine (an anticonvulsant) into a medication cup, located on top of the medication cart. […]

• No harm, potential for more than minimal, isolatedF759Oct 11, 2023

  Based on observation, record review and interview the facility failed to ensure that it is free of medication error rates of five percent or greater. Specifically the medication error rate was 7.69%. Findings include: Review of the facility policy titled Mobile Med Pass and dated March, 10 2017, failed to indicate the nurse is to follow doctor's orders in dispensing medications to a resident. Further review indicated that the nurse is to follow the 5 rights for medication pass. The right patient, the right drug, the right dose, the right route and the right time. Resident #163 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, fractures and dementia. During medication pass on 10/11/23, at 8:58 A.M. […]