Pruitthealth - Marietta
PRUITTHEALTH - MARIETTA in MARIETTA, GA — inspection on January 16, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Orders for rivastigmine tartrate; 3 milligram (mg); 1 cap; oral with a start on 11/2/2023.
Special Instructions: Do not crush.
During the med pass conducted on 1/16/2025 at 8:45 am by a Licensed Practical Nurse (LPN) AA on a R12, it was observed that when administering medications to the resident, she crushed them finely and mixed them with water, stating that the resident could not swallow them.
Upon reviewing the medications, some medications, such as extended-release potassium chloride capsules and rivastigmine tartrate capsules, were identified to not be opened or crushed, as indicated on the medication package and in the order. LPN AA agreed that she should have contacted the pharmacist or the doctor to explore alternative forms of the medications.
When further observing the LPN AA administering Diclofenac gel to the resident, LPN AA was noted to squeeze an unmeasured amount of the ointment into a small medicine cup, locking the tube back into the med cart, and proceeded to the resident's room.
When LPN AA was questioned about how she ensured she was administering the doctor-ordered 4 grams (g) of the gel, the LPN AA admitted she did not know how to measure it correctly.
An interview with a Unit Manager (UM) for the first floor, LPN BB on 1/16/2024 at 12:00 pm revealed that if a resident cannot swallow a pill, they would call the pharmacy to clarify if a medication could be crushed, or if it could be changed to another form.
She further reported that they would then reach out to the doctor to get it okayed by the MD. UM LPN BB reported that the correct way of measuring the diclofenac ointment is to squeeze the gel on a measuring card to ensure the correct dosage is administered.
During an interview with UM LPN CC on 1/16/2025 at 12:05 pm she revealed that if a resident cannot swallow a medication, the nurse should first call the pharmacy to see whether the medication can be changed to another form. UM LPN CC reported the correct way of measuring and administering diclofenac ointment, was to just squeeze the gel into a small medication cup. UM LPN CC further reported that she would use somewhere around 5-15 ml but was unclear on the precise amount.
When asked about using the measuring card that comes with the medication UM LPN CC revealed that she was unaware of the measuring card.
During an interview with the Director of Nursing (DON) on 1/16/2025 at 12:50 pm, it was revealed that if a resident has problems swallowing medication and the extended-release capsule cannot be opened or crushed, they call the pharmacy and then a doctor to get it switched to another form, if possible.
The DON then stated that they do not measure and administer it liberally when referring to the correct way of measuring diclofenac ointment.
The DON acknowledged not being aware that the ointment comes with a measuring card and was not sure if there was a policy concerning this.
115276
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115276 B.
Wing 01/16/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Pruitthealth - Marietta 50 Saine Drive SW Marietta, GA 30008