LOCATED: 5901 OURAY ROAD NW, ALBUQUERQUE, NM 87120
LADERA CENTER 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 MAKE SURE THAT EACH RESIDENT’S DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS; 2) EACH RESIDENT’S ENTIRE DRUG/MEDICATION IS MANAGED AND MONITORED TO ACHIEVE HIGHEST WELL BEING
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility failed to ensure that 1 (R #1) of 4 (R #s 1, 2, 3, 4) residents reviewed for unnecessary medication did not receive excessive doses of pain medication. This deficient practice caused R #1 to:
Become unresponsive and had to be administered [MEDICATION NAME] (a medication used to block the effects of opioids/narcotics, especially in overdose) two times while at the facility.
To be taken by ambulance to the Emergency Department due to the over sedation of [MEDICATION NAME] (a narcotic pain medication).
Record review of the nursing progress note dated 07/25/16 indicated: rsd (resident) sedated, slurring words, unable to hold head up, eyes droopy and sometimes shut with head bobbing downward, and lethargic, rsd states, ‘that is too much, I don’t want it all’. PA (Physician Assistant) notified. Orders obtained to give [MEDICATION NAME] 30 mg x1 dose this 0800 am dose. Will f/u (follow up) with provider regarding sedation of resident, will continue to monitor rsd for safety and status changes.
Record review of the nursing progress note dated 07/25/16 at 8:00 am, indicated that nurse notified of rsd. Slurring words and apparent look of sedation.
Record review of the nursing progress note dated 07/25/16 at 13:14 (1:14 pm). The note indicated that at 12:49 pm too lethargic to take meds nurse notified.
Record review of a progress note dated 07/25/16 at 15:01 (3:01 pm), (Nurse) was called to resident’s room. Resident lying on floor on stomach. Resident stated she leaned over in wheelchair and fell to floor. No new open or discolored areas noted at this time. ROM (range of motion) completed WNL (within normal limits). Neuro checks started, WNL. Doctor made aware via NP (nurse practioner), sister made aware. At present no complaints of pain or discomfort. Presently lying in bed. Alert, verbal, pupils equal and reactive, skin warm and dry, resp (respirations) even and unlabored. Will continue to monitor.
Record review of the physician’s progress note dated 07/27/16 stated that R #1 was sent to the ED (emergency department) on 07/25/16 for over sedation due to her scheduled [MEDICATION NAME]. [MEDICATION NAME] was given x 2 at the facility and patient remained unresponsive, so she was sent to the ED. In the hospital she was found to have a CBG (blood glucose) of 48 (Normal range of 80-110), she stated she hadn’t eaten all day. She returned yesterday morning and [MEDICATION NAME] dose was decreased from 40 mg TID (three times per day) to 10 mg TID.
On 10/26/16 at 10:57 am during an interview with Medication Technician #1, she stated that when she saw R #1 on 07/25/16 she was slouched over in her chair. It was very difficult to get her awake. She was almost comatose. PA (Physician’s Assistant) #1 was made aware of the situation and had us watching and monitoring R #1. The medication was decreased from 40 mg to 30 mg three times per day.
Personal Note from NHA – 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.
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