cms_WV: 102
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 102 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 698 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain effective communication with the [MEDICAL TREATMENT] center and failed to follow-up on communication related to the resident's blood pressure dropping during [MEDICAL TREATMENT]. This affected one of one resident reviewed for [MEDICAL TREATMENT] care in the sample of 28. Resident identifier: #32. Facility census: 176. Findings included: a) Resident #32 On 08/20/18 at 10:39 AM Resident #32 was interviewed in his room. Resident #32 stated that sometimes his blood pressure is low during [MEDICAL TREATMENT] and that he was instructed by the [MEDICAL TREATMENT] clinic not to take his morning blood pressure medication before [MEDICAL TREATMENT]. Resident #32 said he leaves for [MEDICAL TREATMENT] around 06:00 AM and he takes his morning medications before he leaves, but was under the impression that he was not getting his blood pressure medication before he goes to [MEDICAL TREATMENT]. On 08/21/18 at 03:55 PM Resident #32's medical record was reviewed. Resident #32 has intact cognition according to the Minimum Data Sets (MDS), dated [DATE]. Resident #32 had [DIAGNOSES REDACTED]. Resident #32 received [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday, according to the current [MEDICAL TREATMENT] care plan, initiated 05/24/18. The care plan intervention stated, [MEDICAL TREATMENT] Communication Record is sent to the [MEDICAL TREATMENT] center with each appointment and return of form is ensured after appointment is completed. Resident #32 had physician's orders [REDACTED]. [REDACTED]. Resident #32 was scheduled to receive his first doses of [MEDICATION NAME] and [MEDICATION NAME] ER at 0600 (06:00 AM) according to the Medication Administration Record (MAR), dated 08/01/2018 - 08/31/18. Resident #32's progress note, dated 08/5/18, 06:29 read, RES STATED THAT [MEDICAL TREATMENT] NURSE STATES HIS BP IS DROPPING TOO LOW AND NOT TO TAKE HIS BP MEDS PRIOR TO [MEDICAL TREATMENT]. HELD BP MEDS, INFORMED SUPERVISOR AND SIALYSIS PER PROGRESS NOTE. SENT ORDER SHEET W/RES TO [MEDICAL TREATMENT] FOR ORDERS TO BE WRITTEN REGARDING BP MEDS. The progress note was signed by Licensed Practical Nurse (LPN) #70. Resident #32's corresponding [MEDICAL TREATMENT] Communication Record form (Briggs), dated 08/05/18, and completed by LPN #70 read, Res stated that you wanted his blood pressure meds held prior to [MEDICAL TREATMENT]. [MEDICATION NAME] and [MEDICATION NAME] held today. We can change time of BP meds if needed. Pls respond below. There was no response documented from the [MEDICAL TREATMENT] center on the 08/05/18 [MEDICAL TREATMENT] Communication form. The only information completed on the form by the [MEDICAL TREATMENT] center was the resident's pre- and post-[MEDICAL TREATMENT] weights. The following sections where left blank: [MEDICAL TREATMENT] completed without incident?; Problem with access graft/catheter?; Lab work completed?; Medications given at [MEDICAL TREATMENT]; Recommendations/Follow-up. Resident #32's MAR and progress notes were reviewed on 08/23/18 at 10:00 AM. There was no follow-up regarding whether Resident #32's blood pressure medication should be held prior to [MEDICAL TREATMENT] according to review of the progress notes dated 08/05 - 08/23/18 in the medical record. Resident #32's pre-[MEDICAL TREATMENT] blood pressure medications, [MEDICATION NAME] and [MEDICATION NAME] ER, were held on 08/05/18 due to the resident self-report of his blood pressure dropping during [MEDICAL TREATMENT], per documentation in the MAR and progress note dated 08/05/18. Resident #32's blood pressure medications were also held on 08/09/18 and 08/11/18 due to the resident's refusal per documentation in the MAR. Resident #32 received his blood pressure medications on all other pre-[MEDICAL TREATMENT] days including 08/07, 08/14, 08/16, 08/18, 08/21, and 08/23/18 per the MAR. On 08/23/18 at 10:05 AM Registered Nurse (RN) #34 confirmed there was no follow-up documented regarding the 08/05/18 communication to the [MEDICAL TREATMENT] center about the resident's blood pressure medication. RN #34 said Resident #32 continued to receive his blood pressure medications prior to [MEDICAL TREATMENT]. There were no [MEDICAL TREATMENT] Communication Record forms for Resident #32's [MEDICAL TREATMENT] visits of 08/11/18, 08/14/18, and 08/16/18. Resident #32's [MEDICAL TREATMENT] Communication Record forms dated 08/02/18 and 08/21/18 were also incomplete in the section to be completed by the [MEDICAL TREATMENT] center. An interview was conducted with the Director of Nursing (DON) on 08/21/18 at 04:09 PM. The DON stated the nurse should verify that the [MEDICAL TREATMENT] Communication form is completed upon the resident's return to the facility. The DON said if it's not completed they should fax it back to the [MEDICAL TREATMENT] center and request that it be completed. The DON also stated that if the [MEDICAL TREATMENT] center does not send back the [MEDICAL TREATMENT] Communication form the nurse should call the [MEDICAL TREATMENT] center and request the form. The DON confirmed that the [MEDICAL TREATMENT] Communication Record forms for 08/11/18, 08/14/18 and 08/16/18 were not in the record or in the facility. The facility policy titled [MEDICAL TREATMENT], Care of Residents, revised (MONTH) (YEAR), stated in part, 3. A [MEDICAL TREATMENT] Communication Record (Briggs) is initiated and sent to the [MEDICAL TREATMENT] center for each appointment. Ensure it is received upon return. | 2020-09-01 |