Waters of Memphis a Rehabilitation & Nursing CTR

In the surveyor’s words

From the most serious findings on record at Waters of Memphis a Rehabilitation & Nursing CTR, in the surveyor’s own words.

• Immediate jeopardy, patternF684Feb 14, 2022

  Based on policy review, medical record review, observation and interview, the facility failed to ensure medications were administered as ordered by the Physician as evidenced by the dated and timed unit doses of medications remaining in the medication carts and had not been administered for 26 of 33 sampled residents (Resident #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #27, #28, #29, #30, and #31). These failures resulted in Immediate Jeopardy when these residents failed to receive their prescribed medications had the likelihood of a serious adverse outcome and unstable decline in the residents' medical conditions. […]

• Immediate jeopardy, patternF756Feb 14, 2022

  Based on policy review, pharmacy service agreement, medical record review, observation and interview, the facility failed to ensure the pharmacist identified irregularities in Resident #1's cardiac drug regimen when conducting the monthly Medication Regimen Review (MRR) and failed to ensure the pharmacist identified medications were not being administered as scheduled which had the likelihood to cause serious adverse outcomes. The facility's failure resulted in Immediate Jeopardy for 31 of 33 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31), that required significant medications, such as cardiac medications, [CONDITION(S)] medications, diabetes medications,… […]

• Immediate jeopardy, patternF760Feb 14, 2022

  Based on policy review, pharmacy service agreement, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when significant medications including cardiac medications, antiarrhythmics, antihypertensive, anticonvulsant, and antiplatelets were not administered as ordered. One or more unit doses scheduled to be administered prior to 2/8/2022 were observed in the medication carts and had not been administered for 22 of 33 sampled residents (Resident #1, #2, #3, #4, #5, #6, #9, #10, #12, #14, #15, #16, #18, #19, #20, #21, #22, #24, #25, #27, #28, and #30). […]

• Immediate jeopardy, patternF835Feb 14, 2022

  Based on policy review, job description review, pharmacy service agreement, medical record review, observation, and interview, the facility Administration failed to administer the facility in a manner to provide oversight of pharmacy services, failed to provide oversight of nursing services administration of medications to the residents which included the administration of significant medications and other medications, and failed to ensure residents received the highest level of care possible for 30 of 33 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31) reviewed that required medications such as cardiac medications, [CONDITION(S)] medications, diabetes medications,… […]

• Immediate jeopardy, patternF867Feb 14, 2022

  Based on policy review, job description review, pharmacy service agreement, medical record review, observation, and interview the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to ensuring significant heart and [CONDITION(S)] medications and other medications were administered as ordered by the physician, ensure irregularities in the resident's drug regimen were identified and developing corrective actions designed to effect change at the systems level to prevent quality of life, quality of care, or safety problems; and monitor the effectiveness of its performance activities to ensure that improvements were sustained, which had the likelihood to result in… […]