cms_WV: 3597
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
3597 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 842 | E | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure and maintain medical records on each resident that were complete and accurate. This had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #55, #13, #50 and # 376. Facility Census: 76. Findings include: a) Medication Observation and Record Review Medication observation completed on 02/25/20 with Employee # 87, an Licensed Practical Nurse (LPN), found medication was administered to Residents #55, #13 and #50. Review of Medication Administration Records (MAR) and Physician order [REDACTED]. 1) Resident #55's MAR indicated [REDACTED]. [MEDICATION NAME] dose was marked through and new dosage was inserted with no explanation. Further review found the [MEDICATION NAME] dosage had been changed on 10/28/19. Review of the physician orders [REDACTED]. Some of the writing was illegible. 2) Resident #13's MAR indicated [REDACTED]. Review of the physician orders [REDACTED]. Some of the writing was illegible. 3) Resident #50's MAR indicated [REDACTED]. Review of the physician orders [REDACTED]. Some of the writing was illegible During an Interview with the Director of Nursing (DON) on 02/26/20 at 9:00 am, she agreed the physician orders [REDACTED].#55, #13 and #50's did not match with times and dosages and was unable to determine who or when the changes had been made. She also agreed some were illegible. B) Resident #376 Review of Resident #376's medical records revealed an order written [REDACTED]. The administration parameters, or the blood pressure reading that would require the medication, were not specified. Resident #376's Medication Administration Record [REDACTED]. The medication had not been administered since the medication was ordered. On 02/24/20 at 10:17 AM, the Director of Nursing (DON) was informed Resident #376's as needed [MEDICATION NAME] order did not specify the parameters for administration. She had no further information regarding the matter at that time. On 02/25/20 at 9:28 AM, the DON stated Resident #376's as needed [MEDICATION NAME] order was discontinued by the physician. | 2020-09-01 |