cms_WV: 152
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 152 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 684 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, policy review, and medical record review, the facility failed to ensure each resident received medication as physicians orders; which includes the administration of medication timely for five (5) out of thirty-five (35) sampled residents. This failed practice had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #139, #182, #130, #37 and #432. Facility census: 182. Findings included: a) Resident #139 Medical record review for Resident #139, revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident is unresponsive and requires a gastrostomy feeding tube for all nutritional needs and [MEDICAL CONDITION] in place secondary to [MEDICAL CONDITION]. Resident #139 is to receive nothing by mouth (po) secondary to dysphagia and aspiration. Further review of Resident #139's medical records found an order for [REDACTED]. Review of the Controlled Medication Utilization Record for 09/29/19 at 1:00 am through 10/01/19 at 5:00 pm, found Resident #139 received [MEDICATION NAME] 20 mg per 1ml; which equals 20 mgs by mouth (po) every hour. Resident #139 received fifty-one (51) doses of 20 mgs of [MEDICATION NAME] instead of the 4mgs and the resident received the [MEDICATION NAME] po instead of SL as ordered. Interview with attending physician on 10/09/19 at 5:00 pm revealed the [MEDICATION NAME] should be given SL not po and the dosage should be 20mg per 1 ml - give 0.25 ml which equals 4 mg every hour as needed for pain. Clarification orders noted by the attending physician to give SL not po due to aspiration. Interview on 10/10/19 at 10:00 am with the Director of Nursing (DON), found the resident received the wrong dosage of [MEDICATION NAME] on the above dates. Additionally, she confirmed the [MEDICATION NAME] was to be given SL but was documented it was administered po. Review of Resident #139's medical record found an order for [REDACTED]. Order effective 08/15/19. Review of the August, (MONTH) and (MONTH) 2019, Medication Administration Record [REDACTED]. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's blood pressure and heart rate was not taken and documented prior to the administration of the [MEDICATION NAME]. b) Resident #182 Review of Resident #182's medical record found an order for [REDACTED]. Order effective 06/17/19. Review of the June, July, and (MONTH) 2019, Medication Administration Record [REDACTED]. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's heart rate was not taken and documented prior to the administration of the [MEDICATION NAME]. c) Resident #130 During a review of the Medical Administration Record (MAR), it revealed, was ordered: [MEDICATION NAME] Powder 0 Units/Grams, to be applied every shift to the groin. (This is an antibiotic which is used for both fungal and/or yeast infection). It is recommended to be given two (2) three (3) times a day and given at the same time daily. The facility nurses are scheduled from 7:00 AM, to 7:00 PM, and 7:00 PM, to 7:00 AM. Therefore, making the medication due every 12 hours. Below are the times it was administrated: On 10/01/19 due at 7:00 AM- time given-1:58 PM. The next dose due 7:00 PM-time given- 7:25 PM. Making the time between the first dose and the second dose, five (5) hours and 25 minutes. On 10/05/19 due at 7:00 AM- time given-5:10 PM, the second dose due at 7:00 PM-time given- 8:19 PM. Making the time between the first and second dose, three (3) hours and 9 minutes. On 10/06/19 due at 7:00 AM-time given-5:58 PM, the second dose due at 7:00 PM-time given-8:20 PM. Making the time between the first dose and second dose, one (1) hour and 22 minutes. During an interview on 10/09/19 at 12:30 PM, Director of Nursing about late medication administration and being given too close together to the next dose. She said, it can be given anytime during their shift. She was asked if she thought that one (1) hour to five (5) hour was to close together between doses was beneficial? She said, that she would look into it. d) Resident #37 During review of the facility Medication Administration Record [REDACTED] On 10/01/19 the following medications were scheduled to be administrated at 9:00 AM and was documented as given at 11:07 AM. One (1) hour and seven (7) minutes beyond the allotted time: -[MEDICATION NAME] 40 milligrams (mg) once a day (is a diuretic to treat [MEDICAL CONDITION] for congested heart failure) -[MEDICATION NAME] Bisulfate 75 mg once daily (for congested heart failure). -Protein Liquid 30cc twice daily (for wound healing) -[MEDICATION NAME] 25 mg once daily (for hypertension). -Magnesium Oxide 400 mg once daily (supplement) -[MEDICATION NAME] XR 75 mg once daily (for mood disorder). -Bactrim DS 800-160 mg, twice a day (for acute hematogenous osteo[DIAGNOSES REDACTED]-bone infection-) -Acidophilus one (1) capsule twice a day (antibiotic) -[MEDICATION NAME] 325 (65 FE) once a day (for [MEDICAL CONDITION]) On 10/01/19 the following medications were scheduled to be administrated at 9:00 PM, and was documented as given at 11:12 PM, resulting in the medications being given one (1) hour and 17 minutes too late: -Bactrim DS 800/160 mg twice a day (Antibiotic) -Acidophilus twice a day (antibiotic) -[MEDICATION NAME] Solution Pen-injector 15 units at bedtime (used to control diabetes) On 10/02/19 Humalog five (5) units (for treatment of [REDACTED]. The next dose was scheduled for at 12:00 PM, and was documented as being administrated at 1:22 PM, this resulted in instead of of the administration time having four (4) hours between the two (2) scheduled doses, it was only -one (1) hour and 17 minutes- between them. Resident #37's glucose levels on this day were as follows: -6:30 AM, 148 -11:30 AM, 270 -4:30 PM, 94 On 10/02/19 the following medications were scheduled to be administrated at 9:00 AM and was documented as given at 12:05 AM. Two (2) hour and five (5) minutes late. -[MEDICATION NAME] 40 milligrams (mg) once a day (is a diuretic to treat [MEDICAL CONDITION] for congested heart failure) -[MEDICATION NAME] Bisulfate 75 mg once daily (for congested heart failure). -Protein Liquid 30cc twice daily (for wound healing) -[MEDICATION NAME] 25 mg once daily (for hypertension). -Magnesium Oxide 400 mg once daily (supplement) -[MEDICATION NAME] XR 75 mg once daily (for mood disorder). -Bactrim DS 800-160 mg, twice a day (for acute hematogenous osteo[DIAGNOSES REDACTED]-bone infection-) -Acidophilus one (1) capsule twice a day (antibiotic) -[MEDICATION NAME] 325 (65 FE) once a day (for [MEDICAL CONDITION]) On 10/02/19 the following medications were scheduled ti be administrated at 5:00 PM, and was documented as given at 8:36 PM, meaning it was received three (3) hour and 36 minutes late. -Tigecycline 50 mg intravenously two times a day, (for an acute hematogenous osteo[DIAGNOSES REDACTED]). On 10/02/19 the following medications were scheduled ti be administrated at 9:00 PM, and was documented as given at 11:43 PM, meaning it was received one (1) hour and 46 minutes late. -Bactrim DS 800/160 mg twice a day (Antibiotic) -Acidophilus twice a day (antibiotic) -[MEDICATION NAME] Solution Pen-injector 15 units at bedtime (used to control diabetes). On 10/05/19, Humalog five (5) units (for treatment of [REDACTED]. On 10/06/19 the following medications were scheduled to be administrated at 9:00 AM and was documented as given at 11:56 AM. one (1) hour and 56 minutes late. -[MEDICATION NAME] 40 milligrams (mg) once a day (is a diuretic to treat [MEDICAL CONDITION] for congested heart failure) -[MEDICATION NAME] Bisulfate 75 mg once daily (for congested heart failure). -Protein Liquid 30cc twice daily (for wound healing) -[MEDICATION NAME] 25 mg once daily (for hypertension). -Magnesium Oxide 400 mg once daily (supplement) -[MEDICATION NAME] XR 75 mg once daily (for mood disorder). -Bactrim DS 800-160 mg, twice a day (for acute hematogenous osteo[DIAGNOSES REDACTED]-bone infection-) -Acidophilus one (1) capsule twice a day (antibiotic) -[MEDICATION NAME] 325 (65 FE) once a day (for [MEDICAL CONDITION]) During an interview on 10/09/19 at 12:30 PM, Director of Nursing (DoN), was informed about late medication administration and the insulin being given too close. She said, I know it's not right, but I believe the nurses did given the medication on time, but did not document the time until later. She agreed that the nurses can manually enter a time given, however the electronic system records the actual time it was documented, and that time cannot be altered. e) Resident #432 During an interview on 10/07/19 at 11:21 AM, Resident #432 stated, she had to wait eight (8) hours on her first night here for pain medications. She went on to say, waits more than an hour every time she asks for her pain medication. Resident # 432 had knee surgery on 10/01/19 and was admitted to the facility on [DATE]. She was tearful during the interview, and she said, she had to stop her physical therapy just now, because she was in so much pain. The Physical Therapist Assistant #202 was in Resident #432's room at the beginning of the interview. He told her to let the physical therapy department know when she gets her pain under control, and they will try again. She stated, that she was supposed to get the pain medications before she goes to physical therapy. On this day that Resident #432 was in pain she received [MEDICATION NAME] 10-325 mg at 11:12AM. Her last dose was on 10/06/19 at 2:10 PM, which shows she did not receive any pain medication for 21 hours. During review of the facility Medication Administration Record [REDACTED]. On 10/04/19 Resident #432 was ordered [MEDICATION NAME] 10-325 mg every four (4) hours as needed for pain. Licensed Practical Nurse (LPN) #43 recorded the administration time this at 8:25 PM, however the electronic audit record shows this medication was administrated on 10/05/19 at 12:06 AM. Which is a four-hour (4) difference in time. On 10/04/19 the following medications were scheduled for 9:00 PM, and the recorded time documented was 11:46 PM. This was one (1) hour and 46 minutes late: -[MEDICATION NAME] 150 mg (for [MEDICAL CONDITION]) -[MEDICATION NAME] Sodium 100 mg (for constipation) -Requip 3 mg (for restless leg syndrome) The following medications were scheduled for 9:00 PM, and the recorded time documented was 12:13 AM. This was two (2) hours and 13 minutes late. -[MEDICATION NAME] 5 mg (for diabetes) - [MEDICATION NAME] 40 mg ([MEDICAL CONDITION]) On 10/06/19 [MEDICATION NAME] 10-325 mg LPN #167 put 2:00 AM, as the time administration, the electronic audit record shows this medication was administrated at 8:24 AM. This was a seven (7) hour and 24-minute difference in time. This same medication was recorded as being administrated at 8:27 AM. Which was three (3) minutes after the last time this medication was given. [MEDICATION NAME] 10-325 mg (is an opioid pain medication) and is commended to not to be given in a higher dose than 10-325 mg. On 10/06/19 [MEDICATION NAME] 10-325 mg, LPN #37 documented she administrated this medication at 10:09 AM, the electronic audit records show this medication was documented as given at 2:09 PM and again at 2:10 PM. On 10/07/19 the following medication were scheduled administration time was 9:00 AM and was documented on the electronic audit record shows the medication were administrated at 12:42 PM. This resulted in the medications being two (2) hours and 42 minutes late. -[MEDICATION NAME] Solution Pen-injector 1.8 milliliters daily (for diabetic control of blood glucose) -[MEDICATION NAME] Sodium injection 40 mg (use following a surgical joint replacement to prevent blood clots) -[MEDICATION NAME] 50 mg daily (treatment for [REDACTED].>-[MEDICATION NAME] 5 mg twice daily (treatment for [REDACTED].>-[MEDICATION NAME] 150 mg twice daily (treatment for [REDACTED].>-Duloxetine 30 mg daily (treatment for [REDACTED].>-[MEDICATION NAME] 300 mg daily (treatment for [REDACTED].>-[MEDICATION NAME] 40 mg twice daily (for [MEDICAL CONDITION]) -[MEDICATION NAME] XL 25 mg daily (for hypertension) -Aspirin 325 mg daily (used after joint replacement) On 10/07/19 the following medication were scheduled administration time was 1:00 PM and was documented on the electronic audit record shows the medication were administrated at 3:19 PM. This resulted in the the medications being two (2) hours and 19 minutes late, by LPN #50: -[MEDICATION NAME] 40 mg (for hypertension) During an interview on 10/09/19 at 12:30 PM, Director of Nursing (DoN), was informed about late medication administration and the insulin being given too close. She said, I know it's not right, but I believe the nurses did given the medication on time but did not document the time until later. She agreed that the nurses can manually enter a time given, however the electronic system records the actual time it was documented, and that time cannot be altered. | 2020-09-01 |