cms_WV: 1140

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
1140	HOLBROOK HEALTHCARE CENTER	515076	183 HOLBROOK ROAD	BUCKHANNON	WV	26201	2019-01-25	756	E	0	1	K04V11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and staff interview, the pharmacist failed to identify a drug irregularity related to an incomplete medication order without adequate indication for use and adequate monitoring. In addition, the facility failed to develop and maintain policies and procedures for the monthly Medication Regimen Review (MRR) that include, but are not limited to, time frames for the different steps in the monthly medication review process. This practice has the potential to affect all. Resident identifier: #10. Facility census: 84. Findings include: a) Resident #10 Review of Resident (R) #10's medical record on 01/22/19, revealed the following order with a start date of 10/02/2018: [MEDICATION NAME] ([MEDICATION NAME]) tablet; 20 mg (milligrams); amt (amount): 20 mg; oral Special Instructions: dx (diagnosis): [MEDICAL CONDITION] Once a Day - PRN (as needed); PRN 1 The electronic Medication Administration Record [REDACTED]. Pharmacy reviews from 10/04/18 to 01/23/19 note the following identified irregularities: 11/26/18 - [MEDICATION NAME] 250 mg three times a day due for semi annual evaluation of continued use of this [MEDICAL CONDITION] medication. 12/30/18 - [MEDICATION NAME] 20 mg every morning due for semi-annual evaluation for continued use. The monthly pharmacist reviews lack any information related to the incomplete [MEDICATION NAME] order. The Health Information Management Director #13, confirmed there were no other pharmacy recommendations for R#10, for the time period of 10/04/18 through 01/23/19, during an interview on 01/23/19. On 01/23/19 at 2:30 PM, the Director of Nursing (DON) confirmed R#10's [MEDICATION NAME] order was incomplete, lacking an adequate indication for use and adequate monitoring. In addition, the DON acknowledged the pharmacist should have identified this incomplete order during his monthly medication review. b) The facility policy titled Monthly Regimen Review with a revision date of 08/31/2018, states under #2 (typed as written). A licensed pharmacist will perform the medical record review monthly for long term and short term residents, make recommendations if applicable, and communicate to the facility in one of the following ways: a. Verbal communication to prescriber and/or staff b. Written communication to prescriber and/or staff. 3. The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing .4. Upon review of the Pharmacist's recommendations, the facility designee and/or physician, will respond to the recommendations in a timely manner . There are no time frames for each step of the MRR including when the pharmacist should report his findings, when the physician is notified and when the physician should respond. The DON reviewed the Monthly Regimen Review policy during an interview on 01/22/19 01:50 PM, and confirmed the policy does not include time frames for steps in the MRR process.	2020-09-01