cms_WV: 10057
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10057 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2009-10-16 | 514 | D | 0 | 1 | EVU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure medical records were accurate and complete. One (1) resident had expired, but there were no nursing entries regarding the resident's final hours or that there had been a cessation of vital signs. There was no documentation regarding the reason one (1) resident did not take her [MEDICATION NAME], nor was the effectiveness of her pain medication noted. Two (2) of seventeen (17) residents on the sample were affected. Resident identifiers: #91 and #42. Facility census: 89. Findings include: a) Resident #91 1. This resident was selected for closed record review as she had expired in the facility. Review of her medical record found a form entitled "Nursing Transfer / Discharge Note". The form noted the resident had died at 8:35 a.m. on [DATE]. There was information regarding the release of the body to the mortuary, but other sections were blank or marked as "N/A" (not applicable). Review of the nursing entries found an entry for [DATE] at 6:00 a.m., noting the resident had required suctioning three (3) times. The next entry was [DATE] at 1:00 p.m., which noted the physician had been in to see the resident and there were no new orders. From [DATE] at 1:00 p.m. through the time of death on [DATE] at 8:35 a.m., there were no further notes. The findings at the time of death (i.e., there was no heart beat, respirations were absent, etc.) were not identified. It was not noted whether the resident's family had been notified or whether the physician had been made aware of the resident's death. 2. During review of the resident's close medical record, a copy of a CMS-802 with the names of seven (7) other residents was found in Resident #91's file. This document included confidential information such as continence status, whether the individual was cognitively impaired, whether the resident had a [DIAGNOSES REDACTED]. Another document, including the names of thirty-one (31) other residents along with confidential information was also found in Resident #91's closed record. b) Resident #42 1. Review of the resident's medical record noted almost every dose of [MEDICATION NAME] had been circled on the Medication Administration Record [REDACTED]. The reason the [MEDICATION NAME] had been circled was not noted on the designated space on the back of the MAR, nor was it noted in the nurses' notes. According to Employee #11, the resident said she did not need the stool softener. 2. The September "PRN (as needed) Pain Medication Flow Sheet" indicated the resident had been given Tylenol 650 mg five (5) times for generalized pain. The form prompted the nurse to note the effectiveness of the pain medication at intervals of 30 minutes, 1 hour, and 2 hours. Only one (1) of the five (5) had any further entries, and this may have been the nurse's initials. One (1) notation indicated the pain had been an "8" on the pain scale when the medication was given. The nurse had written "9" in the blank for the effectiveness at 30 minutes and the remainder was blank. The "9" would have indicated the pain was worse after 30 minutes and further monitoring / action would have been indicated. . | 2015-07-01 |