Caring Heart Rehabilitation And Nursing Center
Based on staff interviews, review facility policy and clinical record review, it was determined that the nursing home failed to ensure that medication labels were accurate for one of three residents reviewed. Those findings included the following: Clinical record review revealed that Resident1 was admitted to the facility. In review of a reportable event dated February 8, 2012, received via the Pennsylvania Department of Health Event Reporting System indicated that on February 6, 2012, Resident R1 received Vancomycin 1 gm IV in error, and was sent to an acute hospital care for evaluation. In review of the facility’s investigation report revealed that on February 6, 2012, prior to the administration of Resident R1’s dose at 9:00 p.m. of Cefepime HCI 2 gm, it was discovered within the ziplock bag from the pharmacy, one vial of Vancomycin 1 gm was inside. Also inside the ziplock bag was one 100 mL of saline solution, used to mix and administer the medication, labeled as Cefepime HCI 2 gm. The label of the medication did not correspond with the IV bag, per physician’s orders. Inreview of updated facility policy, General Guidelines for the Administration of Medications, revealed that facility staff will provide safe and accurate administration of medication to residents.
In an interview with the Director of Nursing on February 14, 2012, at 10:15 a.m., confirmed that the facility’s pharmacy sent the incorrect IV antibiotic for Resident R1, and as a result, the resident did not receive the antibiotic as ordered by the physician. The facility did not ensure that the pharmacy labeled and dispensed medications as ordered by the physician, to ensure safe and accurate medication administration.
Based on interviews with staff and clinical records, it was determined that the nursing home did not ensure that the residents’ clinical records were complete and accurately documented for two of three records reviewed. Findings included the following: Clinical record review revealed that the resident was admitted to the facility at a specified date. In review of the medication administration record and treatment administration record revealed no documentation that the flushes were performed, per physician’s orders. In an interview with the Director of Nursing on February 14, 2012 at 10:30 a.m., it was confirmed that there was no documentation that PICC lines were performed, per physician’s orders.