cms_WV: 10256
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10256 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-09-26 | 282 | D | 0 | 1 | FJI611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure licensed nursing staff followed the facility's written plan of care for addressing bowel elimination and the facility's care plan for obtaining blood pressure. This was true for three (3) of (31) thirty-one residents reviewed in Stage 2 of the QIS (quality indicator survey.) Resident identifiers: #12, #118, and #207. Facility census: 109. Findings include: a) Resident #12 Review of the Resident's care plan, initiated on 07/25/12, found the problem, "Bowel elimination alteration; constipation related to: lack of exercise, pain medications." The goal associated with this problem was: "Resident will be free of constipation as evidence by having a BM (bowel movement) at least q (every) three days thru review period." Interventions for obtaining the goal included, "Evaluate need for medications that causes constipation; record BM (bowel movement) note size and consistency, report any abnormalities to Licensed nurse, certified Nursing aide report to licensed nursing staff on 3rd day if no BM for further follow-up; observe bowel sounds as indicated, administer medications as ordered to prevent constipation." The Resident Functional Performance Record, completed daily by the nursing assistants, for Resident #12 had no bowel movements recorded from the date of admission, 07/20/12, through 07/28/12, when the resident had a medium bowel movement. Review of the nursing notes found an entry for 07/31/12 at 11:30 a.m., "Resident complained of being constipated gave enema at 11:30 a.m., resident stated still no relief, told oncoming nurse at 3:00 p.m., She stated she see what she can give her." Review of the nursing notes found no documentation from the oncoming nurse regarding the resident's reports of constipation on 07/31/12. The Medication Administration Record [REDACTED]. Additionally, there was no evidence the nurse administering the enema on 07/31/12 received an order from the resident's physician for the enema. Review of the Resident Functional Performance Record found no evidence the resident had a bowel movement on 07/31/12. Her next bowel movement occurred sometime during the day shift on 08/01/12, when a medium bowel movement was recorded. At 9:30 a.m. on 09/26/12, Employee #119, a registered nurse and regional director of clinical services, was interviewed regarding the facility's bowel protocol. She verified the facility did not have any policy or procedures regarding bowel functioning, or standing orders to treat constipation. She said the nurses knew to call the physician if a resident had no bowel movement in three (3) days. Employee #119 was unable to find any written documentation to support her statement. When questioned as to how the facility monitored bowel functioning to prevent fecal impaction, Employee #119 replied the residents' functional performance records were reviewed at morning meetings. If a resident had no bowel movement for three (3) days, the physician was contacted for intervention. A copy of the Functional Performance Record for Resident #12 was presented to Employee #119. Documentation from the nursing assistants verified the resident had no bowel movements from 07/20/12 to 07/28/12, when a medium bowel movement was recorded. Employee #119 was asked if physician intervention was requested during this time frame. She was unable to provide evidence the physician was contacted, or evidence the issue was addressed by the facility. Employee #119 stated she did not know why the facility had not noticed the lack of bowel movements at the daily meetings. A copy of the care plan was reviewed with Employee #119. No further information was provided to verify the facility followed the care plan interventions listed above. Employee #119 verified an order had to be obtained from the physician before giving an enema. She was unable to find documentation the physician was contacted and ordered the enema. No further information was provided to verify nursing staff monitored the resident for bowel sounds, encouraged fluids, reviewed any medications that could have contributed to the resident's constipation, or contacted the physician when the resident had no bowel movement for three (3) days, as directed by the care plan. . . b) Resident #118 Review of this resident's current care plan revealed a goal, "Blood pressure will remain within acceptable limits, systolic between 100-150 and diastolic between 60-90 through next review." The target date, and revised target date, for that goal, was 07/13/12 and 10/09/12, respectively. Review of the Medication Administration Record [REDACTED]. Review of the electronic medical records revealed the last documented blood pressure reading was on 04/27/12. The next blood pressure reading was recorded on a nursing assessment dated [DATE]. There were no other blood pressure recordings, during this time frame, to assess if the resident's blood pressure fell within the care plan's acceptable parameters. On 09/19/12 at 5:45 p.m., a registered nurse, Employee #72, produced "Assessment" policy #CL-676-0005. The policy statement revealed, "It is the center's policy to assess each resident upon admission, re-admission, and quarterly or with significant change in condition." Employee #72 explained the facility did not have a specific blood pressure/vital signs policy. Interim director of nursing, Employee #157, verified this on 09/20/12 at 10:00 a.m. . . c) Resident #207 Resident #207 was a [MEDICAL TREATMENT] patient, who went for [MEDICAL TREATMENT] treatments on Tuesday, Thursday, and Saturday. Review of the care plan and "Quick Reference Guide" identified the facility was supposed to monitor pre and post vital signs, obtain pre and post weights, and observe the site after [MEDICAL TREATMENT] for excess bleeding. Review of the medical record, on 09/24/12, found the facility was not consistently obtaining vital signs prior to and after the resident's return from [MEDICAL TREATMENT]. The facility also failed to obtain pre and post weights from the [MEDICAL TREATMENT] center after each [MEDICAL TREATMENT] treatment. On 09/17/12 the facility obtained a faxed copy of the pre and post weights for the resident's previous visits on 09/15/12, 09/13/12, and 09/11/12. The weights were not obtained following each visit as required by the care plan. Review of a nursing interdisciplinary progress note revealed Employee #68(nurse) failed to assess the resident's site upon return to the facility on [DATE]. Employee #90 (nurse) failed to obtain vital signs prior to [MEDICAL TREATMENT] on the same day. According to the Medication Administration Record, [REDACTED]"Quick Reference Guide" used by the facility. During an interview with Employee #68 on 09/25/12, at approximately 1:45 p.m., she confirmed she did not assess the resident after Resident #207 returned from [MEDICAL TREATMENT] on 09/18/12. . | 2015-05-01 |