AURORA, CO- CHERRY CREEK NURSING CENTER

The facility failed to ensure that before a resident was allowed to self-administer medications, an assessment was conducted to determine if the resident was safe to do so

In an interview on 06/14/2022 at 12:14 PM, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) stated the resident ordered medication online. The ADON stated the resident would not allow the facility to complete a self-administration assessment to see if the resident could safely self-administer medications, and that the resident ordered the medications online and would not provide the medication to the facility.

In an interview on 06/16/2022 at 12:59 PM, the Administrator (ADM) stated the resident should have a self-administration assessment. The ADM stated the facility should ask permission to see what medications the resident ordered and contact the doctor to see if it was appropriate for the resident to take or not. The ADM stated that the facility was ultimately responsible if the facility knew the resident was ordering his/her own medication.

The facility failed to ensure there were physician’s orders and a care plan that addressed the use, care, and monitoring of an indwelling urinary catheter for Resident #160.

Review of the care plan revealed undated special instructions indicating the resident had a urinary catheter in place that was draining well. The care plan did not address the care or monitoring required for the catheter. Review of a Medication Review Summary, dated 06/16/2022, revealed there was no current physician’s order for an indwelling urinary catheter, nor for staff to monitor and care for the catheter.

Facility failed to provide the correct tube feeding formula according to physician orders for Resident #86 and failed to appropriately check tube placement prior to administering medications for Resident #82.

In an interview on 06/15/2022 at 4:05 PM, Registered Nurse (RN) #1 stated the facility ran out of Vital 1.2 tube feeding formula and two to three weeks ago the RN contacted Registered Dietitian (RD) #2, who stated Resident #86’s feeding could be changed to Vital 1.5. RN #1 stated the physician’s order should have been modified to reflect the change. 

In an interview on 06/16/2022 at 1:14 PM, the DON stated if they ran out of a tube feeding formula, the nurse should go to the RD and get a recommendation for something comparable. The DON or ADON would call the physician for a new order. The DON stated the correct formula was available and RN #1 admitted he had hung the incorrect formula; subsequently, she asked RN #1 to write up a medication error.

The facility failed to ensure residents did not receive [CONDITION(S)] medications at an excessive dose by failing to implement pharmacy recommendations for decreases in dosage and discontinuation of a [CONDITION(S)] medication, which had been agreed to and signed for by the physician

The DON stated she was not sure what happened with the recommendations from 05/29/2022, but there was obviously a problem with the recommendations from that day being implemented.