ARBORS AT GALLIPOLIS
LOCATED: 170 PINECREST DRIVE, GALLIPOLIS, OH 45631
ARBORS AT GALLIPOLIS was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO ENSURE RESIDENT’S MEDICATION REGIMEN WAS FREE FROM UNNECESSARY MEDICATIONS
Level of harm – ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and staff interview, the facility failed to ensure Resident #135’s medication regimen was free from unnecessary medications. This resulted in harm to Resident #135 as the resident was sedated and experienced a decline in activities of daily living related to transfers and ambulation. The resident also developed a suspected deep tissue injury (SDTI) pressure ulcer as a result in the decline in condition attributed to the use of unnecessary medication. The facility failed to ensure Resident #121 was adequately monitored related to the use of an anti-psychotic medication. This affected two residents (Resident #135 and #121) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #135 revealed the resident was admitted to the facility 02/28/14 with [DIAGNOSES REDACTED]. The resident did not have any pressure ulcers upon admission and was assessed as being at minimal risk for the development of pressure ulcers.
Continuing: The resident’s eyes were closed and his mouth open. Observation on 04/30/14 at 2:50 P.M. of the resident’s skin revealed that the resident currently had three pressure ulcers including the right outer ankle, the right buttock, and the left heel. The left heel had a four centimeter (cm) by 5.3 cm pressure ulcer with black eschar present. The resident had also developed a new two cm by 1.8 cm purple blister (suspected deep tissue injury) on the right mid outer foot which had not been identified by the facility. Review of the plan of care, dated 03/04/14 and 04/14/14 revealed the resident had a potential for side effects related to [MEDICAL CONDITION] drug use. The goal was for no negative outcomes resulting from the use of the [MEDICAL CONDITION] medications. The interventions included monitoring for periods of lethargy. Review of nurse’s notes from 04/12/14 to 05/01/14 did not reveal any documentation regarding the resident showing any signs of sedation. Interview with STNA #7 on 04/30/14 at 2:45 P.M. revealed Resident #135 had been acting more sleepy since he came back from the hospital the last time. He confirmed the resident sits with his eyes closed. Interview with Registered Nurse #2 on 04/28/14 at 2:50 P.M. revealed she was wondering if the pain medication was making Resident #135 more sleepy. She stated that after she gives him the pain medication at 9:00 A.M., then the rest of the day he has his eyes closed. She confirmed she had also given him pain medication at 2:00 P.M. Interview with Physical Therapist #3 on 05/01/14 at 9:30 A.M. revealed Resident #135 had declined in his ability to walk since admission. She stated he was able to walk initially and now can no longer walk. Record review revealed there was no evidence the physician was aware of the resident’s continued lethargy and no evidence the resident’s medications had been reviewed for possible reductions. This was verified by the DON on 05/01/14 at 10:38 A.M.
2. Review of Resident #121 ‘s clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Review of the April 2014 medication administration records revealed the resident received the medication four times in April 2014, none in March 2014, once in February 2014 and once in January 2014. Review of the consultant pharmacist report, dated 02/18/14 through 02/18/14 the pharmacist documented a recommendation for the resident to have an electrocardiogram (ECG) to monitor the side effects of the medication, [MEDICATION NAME]. The physician’s signature on 02/21/14 stated acceptance of the recommendation and to please implement the monitoring plan outlined on the form. No indication of a plan was documented on the form. Record review revealed no evidence the ECG was performed in accordance with the physician order. The only documentation of an ECG performed on the resident was dated 12/11/13, prior to the resident’s admission to the facility. On 05/05/14 at 8:21 A.M., interview with the DON revealed an ECG had not been completed for the resident following the recommendation of the pharmacist review, which was accepted by the physician in February 2014
Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.
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