Centennial Healthcare And Rehabilitation Center (February 4, 2014)

Physician’s orders were not followed by the nursing home. Findings included the following: Observation of Resident R172 on January 30, 2014 revealed that the resident had a medical condition that capped, which stopped breathing through the mouth and nose. Observation of the resident’s bedside on January 30 or 31 revealed no emergency spare at the bedside for emergency use. Review of the facility’s policy and procedure titled Medication Orders/Reconciliation, not dated revealed that a replacement must be available at the bedside at all times. An interview with the director of nursing services on February 4, 2014 at 11:00a.m. revealed that the nursing hoe had no policy and procedure for capping. Observation of the resident during lunch on January 30, 2014 at 12:20 p.m. revealed that the resident was served turkey breast at lunch that was not chopped. Review of Resident R172’s pharmacy consultation dated January 28, 2014 revealed that the resident was administered 20 mg at 7:00a.m. and 10 mg at 5:00p.m. by mouth on the hospital discharge orders and that while in the facility both doses were being administered at 8:00a.m. totaling 30 mg. A review of the resident’s MAR confirmed that the resident was receiving both doses at 8:00a.m. since the resident was admitted until January 30, 2014. An interview with the director of nursing services on February 4, 2014 confirmed that this was a medication error. Review of the facility’s policy and procedure titled Medication Orders/Reconciliation, not dated, revealed that reconciliation review of medication orders to specify the dosage and frequency of the medication ordered. Resident R130’s plan of care dated November 2013 revealed that the resident’s pacemaker was not monitored as per protocol. Review of the resident’s clinical record revealed that the monitoring was only completed in March 2013 and December 2013, June and September’s monitoring was not completed. A review of the resident’s clinical record revealed that there was no psychology follow-up for behavior interventions completed.

Based on clinical record review and staff interview it was determined that the nursing home failed to provide timely physician visits for two of 25 residents reviewed. Findings include: Review of Resident R130’s clinical record revealed that the resident physician’s progress notes, that would include a review of the resident’s treatment plan, medications and physical assessments completed June 6, 2013 and then again on January 9, 2014, and there was no evidence of resident review by the physician from June 6, 2013 until January 9, 2014 a total of approximately six months.