CHURCH HILL, TN- CHURCH HILL POST-ACUTE AND REHABILITATION CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Ensure that residents are free from significant medication errors.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 

Based on review of facility policy, medical record review and interview the facility failed to ensure 1 (#1) resident was properly identified prior to administration of medications which resulted in the resident receiving another resident’s medication and a significant medication error.

The findings included:
Review of facility policy Administering Medications revised date 4/2019 showed .the individual administering the medications verifies the resident’s identity before giving the resident his/her medication. Methods of identifying the resident include a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel .

Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Delusional Disorder, Atrial Fibrillation, Acute Kidney Failure, and Hypothyroidism.

Review of the admission MDS dated [DATE] revealed a Brief Interview Mental Status score of 13 indicating the resident was cognitively intact. The resident required limited assist for bed mobility, transfers, and Activities of Daily Living with 1 person assist.

Review of a facility Medication Error Report and investigation dated 7/21/2022 showed Registered Nurse (RN) #1 failed to properly identify Resident #1 prior to administration of medications which resulted in Resident #1 being administered Resident #2’s medications during the morning medication pass (7:30 AM-9:00 AM). Resident #1 was administered the following unprescribed medications: Aspirin 81 mg (milligrams), Loratadine tablet 10 mg (allergy medication), Oxybutynin Chloride Extended Relief (ER) (medication for bladder hyperactivity) 5 mg 2 tablets (10mg), Seroquel (antipsychotic) 50 mg 2 tablets (100 mg), Sertraline (antidepressant) 100 mg, Lasix (diuretic) 20 mg tablet, Guaifenesin (cold medicine) ER 600 mg, Magnesium Oxide (hypomagnesmia) 400 mg tablet, Tizanidine (muscle relaxer) HCL 2 mg tablet, Gabapentin (anticonvulsant) Capsule 300 mg 2 tablets (600 mg).

Continued review of the facility investigation revealed Resident #2 refused to take the medications offered b the nurse because she recognized those were not her medications and she reported to a Certified Nurse Assistant (CNA). The CNA immediately reported the information to the Director of Nursing (DON). The DON confirmed with Resident #2 she had been offered the wrong medications. The DON interviewed RN #1 and confirmed a medication error had occurred. The DON and RN #1 assessed Resident #1 and notified the Nurse Practitioner (NP). The NP assessed Resident #1 and ordered the resident to be sent to the hospital for evaluation.

Review of a hospital Discharge Summary dated 7/22/2022 showed Resident #1 was admitted to the hospital for 23 hour observation and .did not demonstrate any signs of acute respiratory distress, cardiac issues or other medial issues .

During an interview with the NP on 9/13/2022 at 12:00 PM she confirmed she was notified of the medication error for Resident #1 that occurred on 7/21/2022 as soon as it was discovered. The NP stated the resident’s vital signs were stable however the resident seemed more somnolent than her normal baseline. The NP discussed the resident’s medical history, current condition with facility staff and the decision was made to send the resident to the hospital for closer observation due to the distance between the facility and hospital if the resident needed additional heart or respiratory support.

Interview with the DON on 9/13/2022 at 12:30 PM confirmed a CNA reported to her Resident #2 said the nurse had tried to give her the wrong medicine and confirmed Resident #1 had been administered the wrong medications. RN #1 reported to her the names on the name plate of the door were reversed and that is why the medication error occurred.

Telephone interview with RN #1 on 9/15/2022 at 10:15 AM revealed the DON had approached him on 7/21/2022 and said she thought Resident #1 had been given the wrong medicine. RN #1 stated they confirmed he had given Resident #1 the medications ordered for Resident #2.