Golden Livingcenter-Stenton (September 20th)
Based on nursing home policy and procedure, staff and resident interviews, observations and review of clinical records, it was determined that the facility failed to follow physician’s orders for the administration of medication for seven residents, for not providing a medical device and following a dietary order for one resident, and for not providing pain medication for one resident. The findings included the following: In review of Resident R63’s clinical record revealed an admission to the facility on an undisclosed date with an unspecified medical diagnosis. In review of nursing documentation on both July 19, 2013, and August 19, 2013 indicated the medication was not in the facility and staff were awaiting pharmacy delivery. The nursing home failed to ensure that the medication was readily available to be administered according to physician’s orders.
In review of Resident R9’s clinical record revealed admission to the facility on an unspecified date with an undisclosed diagnosis. The resident was prescribed a sleep aid, 1 milligram by mouth, at bedtime, for sleep. Both the Administration Record awaited delivery eleven times. Additionally, the medication Phoslo was prescribed, 1334 milligrams by mouth, three times daily after meals. On September 18, 2013, documentation revealed that the facility did not have the medication available and was awaiting delivery. Further, the resident was ordered medical treatment every Tuesday, Thursday and Saturday at an off-site facility. Documentations revealed the medications Phoslo and another undisclosed medication which was prescribed at 1600 milligrams by mouth, three times daily after meals, were routinely not administered on those days that the resident was out of the facility for medical treatment. Nursing documentation revealed a notation that for the dose to be administered at 1:00 p.m., medication was not given. The lack of meditation available to the facility and failure to administer the medication as ordered was verified in an interview with Employee E5, on September 20, 2013 at 9:30 a.m.
In review of physician’s orders dated September 2013 revealed an undisclosed diagnosis. In further review of March 2013, the MAR revealed that the house supplement was not given as ordered on, March 16, 17, 30 and 31, 2013. In review of the MAR for April 2013, revealed that Resident R25 was not given a house supplement on April 13 and 14, 2013. In review of the MAR for May 2013, revealed that the House Supplement was not given on May 4, 2013, as ordered. In review of the nursing progress notes for the indicated that the undisclosed medication and the house supplement was not administered and not available. An interview with Employee E2 on September 18, 2013, at 1:15 p.m. confirmed these findings. In review of Resident R29’s physician’s orders dated September 2013 revealed an undisclosed diagnosis. A review of the nursing progress notes for the dates indicated that the medication was not available and not administered to the resident. An interview with Employee E2, Director of Nursing on September 18, 2013 at 1:15 p.m. confirmed these findings.