RIVERSIDE CARE & REHABILITATION CENTER
LOCATED: 190 EAST HWY. 136, CALHOUN, KY 42327
RIVERSIDE CARE & REHABILITATION 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 RESIDENTS ARE SAFE FROM SERIOUS MEDICATION ERRORS.
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, review of hospital records, and review of the facility’s policy and procedure, it was determined the facility failed to have an effective system to ensure one (1) of three (3) sampled residents (Resident #1) was free of significant medication errors.
Review of the physician’s orders [REDACTED]. However, review of Resident #1’s May 2016 EZMAR (Electronic Medication Administration Record) revealed the resident’s order for [MEDICATION NAME] 6 mg, give one (1) tablet daily, was discontinued after the 05/26/16 dose was administered. The facility’s failure resulted in Resident #1 not receiving seventeen (17) doses of [MEDICATION NAME].
Review of the Progress Notes, dated 06/12/16 at 9:37 AM, revealed Licensed Practical Nurse (LPN) #1 was called to Resident #1’s room due to Resident #1 acting different. Upon entering the room, LPN #1 observed Resident #1 with left sided weakness. The resident’s left pupil was pinpoint and nonreactive, and the resident was nonverbal. Resident #1 required assistance for most movements. LPN #1 tried to evaluate Resident #1’s grasp by instructing the resident to grasp both of her hands at the same time. Resident #1 would grasp one (1) hand, then release and grasp the other hand and release. Resident #1 was then instructed to grasp and hold LPN #1’s hands. When Resident #1 grasped both hands, his/her left sided grasp was noted to be weaker. While LPN #1 and the Charge Nurse were evaluating Resident #1, another Charge Nurse notified the Medical Doctor (MD) and Power of Attorney (POA), the State Guardian on call, and the Emergency Medical Systems (EMS).
Review of the Facility Progress Notes, dated 06/12/16 at 12:33 PM, recorded by LPN #1, revealed the emergency room (ER) Physician called the facility at approximately 11:00 AM to question about Resident #1 receiving [MEDICATION NAME]. Review of the MAR revealed the last dose the resident received was on 05/26/16. LPN #1 called the hospital at approximately 11:30 AM and followed up with the ER Physician and informed him that Resident #1 had not received his/her [MEDICATION NAME].
Interview with LPN #3, on 06/15/16 at 3:10 PM, revealed she was familiar with Resident #1 and was aware he/she took [MEDICATION NAME] every day at 4:00 PM on a routine basis. LPN #3 stated when the resident’s name did not pop up at the 4:00 PM medication pass she did not think anything about it. She stated it never crossed her mind that Resident #1 was not scheduled to receive his/her routine [MEDICATION NAME]. The LPN stated she relied on the EZMAR system to tell her who was due medications at a certain time. Further interview revealed once she entered a physician’s orders [REDACTED]. She stated there would be no way for her to know that the HOA did not transfer over to the medication pass side.
Further interview with the DON revealed Resident #1 had missed seventeen (17) doses of [MEDICATION NAME], which would be considered a significant medication error. She stated, However, it would be my expectation as the DON that a resident who has been receiving medication on a routine basis and suddenly that medication is not on the MAR for administration, for the nurse to go check the physician’s orders [REDACTED]. She stated, We have had an influx of inconsistent nursing staff on that unit for the last several weeks, not a shortage, but not the same staff who were familiar with Resident #1’s routine medications, and when working the floor, the nursing staff relied heavily on the EZMAR system to know who to administer medications to and what time the medications were due.
Interview with Resident #1’s Physician, on 06/15/16 at 3:47 PM, revealed Resident #1 has been on [MEDICATION NAME] for many years for [MEDICAL CONDITION] Fibrillation and missing seventeen (17) doses of [MEDICATION NAME] would be considered a significant medication error and could lead to a potential stroke, clot, or [MEDICAL CONDITION] Fibrillation.
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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We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
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