cms_WV: 10573
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
10573 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 514 | E | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the completeness and/or the accuracy of the medical records within acceptable professional standards for five (5) of twenty-three (23) sampled residents. Resident identifiers: #25, #115, #6, #38, and #9. Facility census: 114. Findings include: a) Resident #25 A review of the physician's orders [REDACTED].) The resident's Medication Administration Record [REDACTED]. This finding was pointed out to the assistant director of nursing at 9:50 a.m. on 10/20/09, who acknowledged the double orders and stated she would clarify the order. b) Resident #115 Resident #115's closed medical record, when reviewed on 10/21/09 at 3:00 p.m., disclosed a [AGE] year old female who was discharged from the facility on 09/24/09. The resident was receiving physical therapy post-operatively after a recent [MEDICAL CONDITION]. The admission physician orders, dated 07/10/09, reported the physician had ordered [MEDICATION NAME] 40 mg via subcutaneous injection every day for twelve (12) weeks. The July 2009 MAR indicated [REDACTED]. There was no evidence in the medical record the physician had discontinued the medication. The director of nurses (DON - Employee #121), when interviewed on 10/22/09 at 1:00 p.m., reported the primary physician gave a verbal order to discontinued the medication twenty-one (21) days post-operation. The DON acknowledged there was no evidence in the medical record to indicate the verbal order was received or signed by the physician. c) Resident #6 Resident #6's medical record, when reviewed on 10/20/09 at 11:30 a.m., revealed the October 2009 treatment sheet was incomplete for nurses' initials indicating treatments were completed as ordered by the physician. The physician orders [REDACTED]. The remedy skin repair cream treatment was not initialed for 10/10/09, 10/11/09, 10/12/09, 10/15/09, and 10/16/09 for 3:00 p.m.-11:00 p.m. shifts. The DON, when interviewed on 10/21/09 at 10:30 a.m., related the resident was not out of the facility on the above dates and stated, "I could not say, if the treatment were or were not done." Resident #6 was observed, on 10/20/09 at 10:00 a.m., with the treatment nurse (Employee #28). The resident's skin was intact without any breakdown or redness observed. d) Resident #38 Resident #38's medical record, when reviewed on 10/20/09 at 11:00 a.m., revealed the October 2009 treatment sheet was incomplete for nurses' initials indicating the treatment was completed as ordered by the physician. The physician ordered [MEDICATION NAME] cream to toes daily; this treatment was not initialed as having been completed on the following dates: 10/07/09, 10/10/09, 10/11/09, 10/12/09, 10/15/09, and 10/16/09. The DON, when interviewed on 10/21/09 at 10:30 a.m., related the resident was not out of the facility on the above dates and stated, "I could not say, if the treatment were or were not done." Resident #38 was observed, on 10/20/09 at 9:45 a.m., with Employee #28. The resident's toes were observed, and no redness or rash was noted. e) Resident #109 Resident #109's medical record, when reviewed on 10/21/09 at 11:30 a.m., revealed the September 2009 treatment sheet was incomplete for nurses' initials indicating treatments were completed as ordered by the physician. The physician ordered skin prep to both heels, elevate heels, and Sensicare cream every shift. The treatment sheet was not initialed for the following dates: 09/22/09, 09/23/09, 09/24/09, and 09/25/09 for the 3:00 p.m.-11:00 p.m. shift. Review of the medical record did not show any evidence the resident was out of the facility at the time the treatment were to be completed. | 2015-01-01 |