cms_WV: 3906
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3906 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2016-07-27 | 279 | E | 0 | 1 | H9WH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to use the results of the assessment to develop, review, and/or revise the residents' comprehensive care plans. Six (6) of twenty-one (21) sampled residents' care plans lacked individualized, measurable, objectives and time tables. The care plans failed to address the long-term use of psychoactive medications and/or anticoagulants. Resident identifiers: #85, #39, #74, #42, #92, #21. Facility census: 85. Findings include: a) Resident #85 Review of the medical record, on 07/26/16 at 10:30 a.m., found the significant change minimum data set (MDS), with assessment reference date (ARD) of 02/10/16, assessed that she received antidepressant medications seven (7) days per week. The most recent quarterly assessment, with ARD 05/04/16, said the same. Review of the medical record found the resident with the following Diagnoses: [REDACTED]. She received various dosages of [MEDICATION NAME] since 01/27/15. Currently, she receives [MEDICATION NAME] thirty (30) milligrams (mg) daily. On 06/15/16 she began an antipsychotic medication ([MEDICATION NAME]), one (1) mg. daily. On 06/22/16 the physician changed the dosage of [MEDICATION NAME] to 0.5 mg. twice daily. Review of the care plan found the only mention of psychoactive medication use fell under the focus area of risk for falls. The care plan stated receives antidepressants. The care plan was silent for the use of the antipsychotic medication ([MEDICATION NAME]), or the potential side effects of the psychoactive medications. The care plan was silent for the goals the facility hoped to achieve related to the use of the antidepressant and antipsychotic medications. An interview was conducted with the MDS/Registered Nurse (MDS/RN) #124 on 07/26/16 at 11:15 a.m. She acknowledged that the resident had been on antidepressant medications for a long time. She said the antipsychotic medication ([MEDICATION NAME]) was fairly new, and would show on the latest MDS which is still in progress. She printed a copy of the current care plan and reviewed it. She agreed the care plan did not specify the use of psychoactive medications as a treatment of [REDACTED]. She said social services and the nursing clinical coordinator attend the behavior meetings, and reviewed and revise the care plan accordingly at those times. MDS/RN #124 said she does not attend those meetings. b) Resident #39 Review of the medical record, on 07/26/16 at 1:00 p.m., found the annual minimum data set (MDS) with an assessment reference date (ARD) of 01/06/16, assessed that he received antipsychotic and antidepressant medication seven (7) days per week. The most recent quarterly assessment, with an ARD 06/22/16, said the same. Review of the medical record found the resident had the following Diagnoses: [REDACTED]. Medications prescribed for the treatment of [REDACTED]. He had remained on this medication, although in varying dosages, except for a brief trial discontinuance. Currently, he receives [MEDICATION NAME] two (2) milligrams daily. Other current psychoactive medications includes [MEDICATION NAME], an antidepressant, that he has received since 06/16/14. Currently, he takes [MEDICATION NAME] twenty (20) milligrams daily. Review of the care plan found the only mention of psychoactive medication use fell under the focus area An interview was conducted with the MDS/RN #124 on 07/26/16 at 1:45 p.m. She said the MDS assessments were correct in the identifications of the daily use of antipsychotic and antidepressant medications. She said social services and the nursing clinical coordinator attend the behavior meetings, and review and revise the care plan accordingly at those times. She said she does not attend those behavior meetings, so had no input into the development of the care plan related to the [MEDICAL CONDITION] medications. c) Resident #74 On 07/25/16 at 11:51 a.m., review of medical records revealed a [DIAGNOSES REDACTED]. Review of the medical records also revealed the resident received the anti-psychotic [MEDICATION NAME] at bedtime with a start date of 04/13/16, Brintellix for major [MEDICAL CONDITION] with a start date of 03/16/16, and scheduled Electroconvulsive Therapy (ECT). Continued review of the medical records revealed a physician order [REDACTED]. The resident received ECT on a periodic basis up to the last physician order [REDACTED]. The current care plan for Resident #74 revealed no evidence of the resident receiving ECT's nor evidence of interventions and medication side effects monitoring related to receiving the [MEDICATION NAME] and Brintellix. During an interview on 07/26/16 at 1:20 p.m., MDS/RN #124 agreed the care plan did not include information related to the resident receiving ECT nor did the care plan include interventions and medication side effects related to the resident receiving [MEDICATION NAME] and Brintellix. Resident #42 d) Review of medical records for Resident #42, on 07/25/16 at 2:45 p.m., revealed the resident was prescribed an anti-depressant, [MEDICATION NAME] with a start date of 09/30/14 and a gradual dose reduction date of 07/13/16. The current care plan revealed no evidence of interventions or monitoring for medication side effects related to the resident receiving [MEDICATION NAME]. During an interview, on 07/26/16 at 1:20 p.m., MDS/RN #124 agreed the care plan did not include interventions and monitoring of side effects of the anti-depressant [MEDICATION NAME]. e) Resident #92 A review of the clinical record, at 8:00 a.m. on 07/26/16, Resident #92 had the following [DIAGNOSES REDACTED]. She received the following psychoactive medications per order of her attending physician: --[MEDICATION NAME] HCL, 15 milligram (mg) tablet, twice a day related to generalized anxiety disorder; --[MEDICATION NAME], 1mg tablet, at bedtime for [MEDICAL CONDITION] in absence of dementia related to unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition; and --[MEDICATION NAME], 125 mg, once a day related to generalized anxiety disorder due to known physiological condition. The resident was seen by a psychiatric consultant and her most recent visit was 06/21/16. The physician suggested increasing the resident's dosage of [MEDICATION NAME], stating: Resident continues delusional. Refuses O2 and meds (medication), including insulin at times. Paranoid, thinks she is being poisoned, etc. The attending physician agreed to the change and so ordered the change in medication dosage. A review of the Care Plan, at 9:00 a.m. on 07/26/16, failed to reveal any evidence the continued use of psychoactive medications had been identified as a potential problem; a measurable goal had been developed that could be used to evaluate the resident's progress or decline on those medications; or that nursing interventions had been established and initiated to assist the resident in meeting said goal. During an interview with RN/MDS #124, at 10:30 a.m. on 07/26/16, she acknowledged, after reviewing the entire care plan, the use of psychoactive medications was not addressed as a potential problem. She said nurses include the assessment of these medications in the nurse's notes, but agreed there was nothing in the care plan to do this. f) Resident #21 A review of the clinical record, on 07/20/16 at 9:30 a.m., revealed Resident #21 was assessed as non-communicative, total care for all activities of daily living, and had a feeding tube. Her [DIAGNOSES REDACTED]. Observation of the resident on 07/19/16 at 10:30 a.m. and a family interview with her daughter at 11:00 a.m. on 07/19/16 agreed with the above assessment and diagnoses. During the interview with the resident's daughter, she said the resident had been on anticoagulants for years because of her stroke and her pacemaker, but they were discontinued in (MONTH) (YEAR) prior to her receiving eye surgery. She said a month ago she discovered the medication had never been reordered after the surgery and had the nurse contact the physician. The medication was reordered at that time. Review of the clinical record revealed the resident had been receiving [MEDICATION NAME] 30 mg (milligram) sq (subcutaneous) injection daily until it was discontinued on 10/07/15. The medication was reordered on [DATE], and continues as an active order. The resident's use of an anticoagulant was also identified on the MDS (Minimum Data Set). A review of the resident's care plan revealed several problems addressed related to her [MEDICAL CONDITION] to her pacemaker, but the care plan was silent regarding her long term and/or current anticoagulant drug therapy. During an interview with the Director of Nurses (DON), at 10:30 a.m. on 07/21/16, the DON acknowledged, after reviewing the record, the care plan did not identify the resident's use of an anticoagulant as a potential problem and; therefore, had not initiated any nursing interventions directed at the monitoring of the medication. The DON agreed that recent documented observations of bleeding at the gastrostomy site and during peri care may have been reported sooner if the monitoring had been a care plan intervention communicated to the primary caregivers. | 2020-04-01 |