cms_WV: 3865
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3865 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 309 | E | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and resident interview, the facility failed to implement Resident #78's physician's orders for finger stick blood sugars and sliding scale insulin coverage for twenty-five (25) days after admission. For Resident #78, the facility also failed to obtain an ordered basic metabolic panel (BMP), failed to ensure the resident kept an appointment with a consulting physician ([MEDICATION NAME]), and failed to administer/hold an antihypertensive ([MEDICATION NAME]) according to the physician ordered parameters. For Resident #9, the facility failed to ensure arrangements were provided for two appointments with consulting physicians (psychiatrist and urologist), failed to administer [MEDICATION NAME] (steroid) as directed for the treatment of [REDACTED]. For Resident #10, the facility failed to administer Nepro (supplement) as directed by the physician orders. The physician ordered the supplement to be given three (3) times a day, but the facility only administered it twice daily. For Resident #27, the facility failed to establish a care plan based on the resident's assessed needs for transfers. For Resident #69, the facility failed to follow the physician's parameters for insulin and the nursing staff held the resident's insulin without physician input. This was true for five (5) of eighteen (18) sampled stage 2 residents reviewed during Quality Indicator Survey (QIS). Resident identifiers: #78, #9, #10, #27, #69. Facility Census: 62 Findings include: a) Resident #78 Review of Resident #78 medical records on 01/18/17 at 10:00 a.m. found this seventy-seven (77) year old female was admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. Discharge instructions from the acute care facility and approved by the attending physician at the facility included: 1. Finger sticks before meals and night (four times daily) for thirty (30) days and administer sliding scale insulin using [MEDICATION NAME] Regular insulin PRN (as needed) as follows: -- less than 150 - no insulin -- 151-200 - 2 units of insulin -- 201-250 - 4 units of insulin -- 251-300 - 6 units of insulin -- 301-350 - 8 units of insulin -- greater than 350 - give 10 units of insulin and call the physician Review of the resident's Medication Administration Record (MAR) for (MONTH) (YEAR), found the finger sticks and sliding scale were not completed from 08/03/16 through 08/25/16. 2. On 08/25/16, the physician ordered, Finger sticks twice daily and contact the physician blood sugar is less than 60 or greater than 350. Further review of the MAR and nurses' notes for (MONTH) (YEAR) found the resident's blood sugar was 377 at 6:00 a.m. on 08/28/16. There was no evidence the physician was notified. On 08/29/16, the physician ordered, Finger sticks twice daily and contact the physician blood sugar is less than 60 or greater than 400. Review of MAR and nurse's notes for (MONTH) and (MONTH) (YEAR), found: -- on 09/04/16 at 6:00 a.m. blood sugar was 430, -- on 09/11/16 at 6:00 a.m. blood sugar 400, and -- on 09/05/16 at 4:00 p.m. blood sugar 423. The record contained no evidence the physician was notified. 3. The physician ordered a complete blood count (CBC), basic metabolic panel (BMP) and [MEDICATION NAME] time/international ratio (PT/INR) in two days (08/05/16) then as directed by the facility physician. Record review found no evidence the BMP was obtained on 08/05/16 4. Review of the resident's medical record found an appointment with ([MEDICATION NAME]'s Name) on 08/16/16 at 12:15 p.m. was not attended. 5. [MEDICATION NAME] (antihypertension medication) 12.5 milligrams (mg) through feeding tube twice daily. Hold if systolic blood pressure (b/p) is less than 110 or if heart rate/pulse less than 70. Review of the MAR for August, September, October, November, and (MONTH) (YEAR) and (MONTH) (YEAR) found the following the following issues: -- 08/03/16 at 10:00 p.m. - no pulse obtained -- 08/04/16 at 10:00 a.m. and 10:00 p.m. - no pulses obtained -- 08/05/16 at 10:00 p.m. pulse 98- [MEDICATION NAME] not given -- 08/11/16 at 10:00 p.m. pulse 84-[MEDICATION NAME] not given -- 08/16/16 at 10:00 p.m. - no blood pressure obtained -- 08/18/16 at 10:00 p.m. - no blood pressure obtained -- 08/26/16 at 10:00 p.m. - no blood pressure obtained -- 08/30/16 at 10:00 p.m. - no blood pressure or pulse obtained -- 08/31/16 at 10:00 p.m. - no blood pressure or pulse obtained -- 09/01/16 through 09/15/16 at 9:00 a.m. no pulses obtained (total of 15 days) -- 11/18/16 at 9:00 a.m. - Pulse 68- medication given -- 11/23/16 at 9:00 p.m. - Pulse 68- medication given -- 11/24/16 at 9:00 a.m. - Pulse 68- medication given -- 11/24/16 at 9:00 p.m. - Pulse 66- medication given -- 11/25/16 at 9:00 p.m. - Pulse 68- medication given -- 11/28/16 at 9:00 p.m. - Pulse 68- medication given -- 12/02/16 at 9:00 p.m. - Pulse 68- medication given -- 12/06/16 at 9:00 p.m. - No pulse- medication given -- 12/20/16 at 9:00 p.m. - Pulse 68- medication given -- 12/24/16 at 9:00 p.m. - Pulse 68- medication given -- 01/14/17 at 9:00 a.m. - Pulse 68- medication given During an interview with Corporate Registered Nurse (CRN) #108, Registered Nurse (RN) #109 (the former director of nursing (DON), the current DON, and the Nursing Home Administrator (NHA) on 01/19/17 at 11:00 a.m., the following were reviewed/discussed: -- The resident's medical records, since admission on 08/03/16 through 08/25/16, did not contain evidence of finger sticks with sliding scale coverage as ordered. -- It was confirmed on 08/28/16, 09/04/16, 09/05/16, and 09/11/16, the physician was not notified of blood sugars above the physician-established parameters. -- It was verified Resident #78 was not sent to the scheduled appointment with the [MEDICATION NAME] -- A BMP was not obtained on 08/05/16 as ordered -- Review of the blood pressures and pulses for the physician prescribed parameters were not obtained and/or the medication was not held or not given according to the physician-established parameters. b) Resident #9 Review of Resident #9's medical records on 01/18/17 at 2:00 p.m., found this eighty-six (86) year old female, admitted to the facility on [DATE] from an acute care hospital, had [DIAGNOSES REDACTED]. 1. Discharge instructions from the acute care facility and approved by her attending physician at the facility included appointments with a psychiatrist in two (2) to three (3) weeks for follow-up for major [MEDICAL CONDITION] and with a urologist in four (4) weeks for retention of urine and recurrent urinary tract infections. 2. Review of physician's orders found an order written [REDACTED]. This was ordered for an exacerbation of the resident's [MEDICAL CONDITION]. The [MEDICATION NAME] was started on 12/23/16 and the resident was given 40 mg on 12/23/16, 12/24/16, and 12/25/16 at 9:00 a.m. On 12/26/16, Resident #9 should have received [MEDICATION NAME] 30 mg, but did not receive that dose until 12/27/16. 3. Review of the physician's orders found an order dated 11/17/16 for, Finger sticks twice daily. Call the doctor if blood sugar is less than 60 or if blood sugar greater than 350. Review of the (MONTH) and (MONTH) (YEAR) MARs and nurses' notes revealed: -- 12/17/16 at 4:30 p.m. - blood sugar 372 - no notification of doctor -- 12/24/16 at 6:00 a.m. - blood sugar 376 - no notification of doctor -- 12/25/16 at 4:30 p.m. - blood sugar 398 - no notification of doctor During an interview with Corporate Registered Nurse (CRN) #108, Registered Nurse (RN) #109 (the previous director of nursing) (DON), RN #110, the current DON, and the Nursing Home Administrator (NHA) on 01/19/17 at 11:00 a.m., review of Resident #9's medical records verified: -- the facility failed to schedule the appointments as directed, -- Resident #9 missed a dose of [MEDICATION NAME] on 12/26/16, and -- Resident #9's blood sugar was outside of the physician-established parameters and the physician was not notified. c) Resident #10 A review of Resident #10's medical record at 10:22 a.m. on 01/17/16 found a physician's order dated 12/26/16 for, Nepro three (3) times a day for supplement. Review of the electronic system used by the Nurse Aides to document supplement percentages and other care provide to a resident, revealed the percentage of the Nepro Resident #10 consumed in the last 14 days (from 01/04/17 through 01/17/17) was only documented twice (2) daily. An interview with Registered Nurse (RN) #109 at 3:57 p.m. on 01/18/17 confirmed the supplement was documented in the record as given twice daily instead of three times daily as ordered by the physician. RN #109 then reviewed the resident's Medication Administration Record and confirmed it was not documented there either. She confirmed that according to the documentation Resident #10 only received her Nepro supplement two (2) times a day instead of the ordered three (3) times a day. d) Resident #27 A review of Resident #27's medical record at 9:25 a.m. on 01/19/17 found a Lift/Transfer Tool completed by Licensed Practical Nurse (LPN) #68 on 10/19/16. The facility used the Lift/Transfer Tool to assesses how a resident should be transferred from surface to surface i.e. bed to chair and/or chair to bed safely. The tool identified five (5) lift options the assessor could select based on the accurate completion of the assessment of Resident #27's ability's and condition. The 5 options were: -- No lift needed. (Suggest use of gait belt.) -- Sit to stand Lift is required. -- Total Lift required. -- Transfer requires assist of 2 (two) staff with use of gait belt. -- Consult Therapy Services to determine transfer assist level. Review of the Lift/Transfer tool completed by LPN #68 for Resident #27 found the LPN had chosen three (3) options for safe transfer for Resident #27: -- No lift needed (Suggest use of gait belt.) -- Sit to Stand lift is required. -- Transfer requires assist of 2 staff with the use of gait belt. Review of Resident #27's care plan found Resident #27 was to be transferred with the assistance of one (1) staff member. The care plan did not mention the use of a gait belt or the use of a sit to stand lift. An interview with RN #109 and Corporate RN #108 at 11:33 a.m. on 01/19/2017, confirmed the lift transfer tool for Resident #27 was not completed correctly; therefore it did not fulfill its intended purpose of telling staff how Resident #27 should be transferred. They agreed the form was not clear on how the resident should have been transferred during her stay and therefore one could not be certain if the one person assist for transfers identified on the care plan was the correct and safest way to transfer Resident #27. e) Resident #69 During Stage 1 of the Quality Indicator Survey (QIS), the resident said he was worried the facility was, Going to kill me with insulin. He said the nurses came into his room to give his insulin and they had not even taken his blood sugar first. They can't give me insulin if they don't check my blood sugar first, just think what could happen if I didn't ask them. The resident, admitted to the facility on [DATE], had capacity to make medical decisions. Review of the current physician's orders dated 01/03/16 found an order to obtain accuchecks at AC (before meals) and HS (before sleep). The parameters specified to contact the physician if the blood sugar (BS) was less than 60 or greater than 400. Review of the medication administration record (MAR) for (MONTH) (YEAR) found the resident was receiving the following insulins for treatment of [REDACTED].>-- [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 6 units subcutaneously after meals for diabetes mellitus. -- [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 25 unit subcutaneously at bedtime for diabetes mellitus. In (MONTH) (YEAR), the resident was to receive: -- [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 10 units subcutaneously after meals for diabetes mellitus. -- [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 35 unit subcutaneously at bedtime for diabetes mellitus. The MAR for (MONTH) (YEAR) noted the resident's [MEDICATION NAME] remained the same, but the [MEDICATION NAME] 100 units/ml was increased to 12 units on 01/12/17. At 9:47 a.m. on 01/18/17, the resident's MARs for 08/03/16 through 01/18/17 were reviewed with the Corporate Registered Nurse (RN #108) and RN #109 (the former acting director of nursing). The review identified the following: -- On 08/19/16, 08/21/16, 08/30/16, and 08/31/16, the nurse initialed and circled the resident's 6:00 a.m. dose of [MEDICATION NAME] solution. RN #108 verified the nurses' initials that were circled, indicated the medication was not given. -- On 10/20/16, the nurse again initialed and circled the resident's 8:15 a.m. dose of [MEDICATION NAME]. -- On 01/15/17 at 9:53 a.m., a nurse wrote a progress note indicating the resident's [MEDICATION NAME] solution was held due to a low blood sugar and at the request of the resident. RN #108 and RN #109 verified the insulin could not be held without physician's orders. Both RNs were unable to find verification the physician was contacted and advised the nurse to hold the insulin. -- In addition, the resident's blood sugar was 53 on 08/19/16 at 6:00 a.m. There was no evidence the physician was contacted per the parameters specified with the accuchecks. -- Review of the MARs from 08/03/16 through 01/18/17 found the facility obtained the resident's blood sugars at 6:00 a.m. and 5:00 p.m. The physician's order dated 08/04/16 directed Accu-checks AC (before meals) and HS (hour of sleep) which was two (2) times a day. The resident received three (3) meals a day, meaning the resident's blood sugars should have been completed four (4) times a day, not two (2). | 2020-04-01 |