cms_WV: 10284
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10284 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2012-01-30 | 514 | D | 1 | 0 | LNV211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, record review, policy review, and staff interview, the medical records for two (2) of nine (9) sampled residents were not complete and / or accurately documented. The facility's policy for documentation of [MEDICAL CONDITION] care and documentation for [MEDICAL CONDITION] suctioning were not followed for Resident #9. The facility also did not maintain accurate bowel records for Resident #90. Resident identifiers: #90 and #9. Facility Census: 159. Findings Include: a) Resident #90 This resident had a [DIAGNOSES REDACTED]. She also had some problems with constipation. She had diabetes, high blood pressure, chronic pain, dehydration, and [MEDICAL CONDITION]. The resident received daily medications for her bowels for regularity purposes. The resident was having problems with constipation as evidenced by review of her January 2012 bowel records. On 01/03/12, the resident's third day without a bowel movement, the facility's bowel protocol was initiated according to facility policy. The resident did not have a bowel movement. So on the fourth day (01/04/12), the next step of the bowel protocol was implemented by inserting a rectal suppository. According to the nursing notes, the resident (who was alert and oriented) did not want further interventions until waiting to see whether the suppository worked for her by the next day. The nurse called the doctor, on 01/07/12, due to the resident's constipation. The doctor ordered an enema. The nurse administered the enema, but no bowel movement resulted. She called the physician and orders were received to transfer the resident to the hospital. Her admitting [DIAGNOSES REDACTED]. The medical record contained documentation the resident had results from the suppository. The documentation noted she had an extra-large bowel movement on 01/05/12 on the midnight shift, and an extra-large bowel movement on 01/06/12 on the day shift. During an interview with Employee #86, a nurse, regarding this discrepancy on 01/29/12, she stated the bowel record was not accurate. She stated someone went back and marked the bowel movements after she administered the medication to the resident. The nurse stated the resident told her she had not had a bowel movement. Additionally, on some days there was documentation the resident did not have a bowel movement and also on the same day there was documentation the resident had a large bowel movement. It was not possible to determine which was accurate for this resident. At that time, it was confirmed bowel records were not accurate for this resident. b) Resident #9 During an observation of Resident #9's [MEDICAL CONDITION] suctioning and care, on 01/27/12 at 10:50 a.m., the nurse (Employee # 151) was observed suctioning the resident and providing [MEDICAL CONDITION] care according to the facility's policy. The policy for these procedures concluded with instructions of what information needed to be documented in the medical record. The policy and procedure for [MEDICAL CONDITION] Suctioning instructed to document the following: "38.1 Date and time of procedure 38.2 Amount, color, and consistency of secretions 38.3 Breath Sounds, respiratory rate, cough effort pre and post procedure 38.4 Patients response to suctioning." The policy and procedure for [MEDICAL CONDITION] care instructed documentation as follows: "33.1 Date and time of procedure 33.2 Observations of skin at stoma site 33.3 Breath sounds, heart rate, respiratory rate, and cough effort pre and post procedure 33.4 Patients response to the procedure." This information was not recorded in the medical record following the resident's [MEDICAL CONDITION] care. The treatment record was reviewed. This review revealed only a place to initial that [MEDICAL CONDITION] care had been done. There was no assigned space for documentation of the other things which required assessment and documentation according to the facility's policy. Although the nurse was observed listening to breath sounds and assessing the resident prior to the procedure, there was nothing documented regarding this, as required by facility policy. . | 2015-05-01 |