cms_WV: 4055
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4055 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 157 | E | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to notify Resident #139's attending physician when she experienced numerous episodes of [MEDICAL CONDITION] (low blood pressure) while receiving two (2) medications for hypertension (high blood pressure). This was true for one (1) of seventeen (17) sampled residents. Resident Identifier: #139. Facility Census: 100. Findings include: a) Resident #139 Review of Resident #139's medical record at 12:28 p.m. on [DATE], found she was admitted to the facility on [DATE] shortly after midnight. She was admitted from the hospital where she had the right upper lobe of her lung removed. She remained at the facility until she expired on [DATE]. Resident #139's admitting [DIAGNOSES REDACTED]. Resident #139's discharge medications from the hospital included the following medications used to treat hypertension: - [MEDICATION NAME] 25 milligrams (mg) every 12 hours, and - Amidarone 200 mg 2 tablets daily for seven (7) days then decrease to 200 mg daily thereafter. Review of the facility's admission orders [REDACTED]. Review of Resident #139's nursing admission assessment dated [DATE] at 12:45 a.m., found the resident's blood pressure on admission was ,[DATE] and she was orientated to person, place, and time. Further review of the record found that on [DATE] at 11:46 a.m., Resident #139's blood pressure was ,[DATE]. Further review of the record found a change in condition nursing note written at 9:40 p.m. on [DATE]. This change in condition note indicated Resident #139 had an unwitnessed fall in her room. At the time of her fall, the nurse obtained her vital signs. At 9:00 p.m., her blood pressure was recorded as ,[DATE]. The nurse also indicated the resident was confused. The resident's attending physician was notified of the fall, but there was no evidence to suggest that he was notified of Resident #139's [MEDICAL CONDITION]. ([MEDICAL CONDITION] can cause dizziness, which can contribute to falling.) The nurse indicated that neurological checks were initiated as a result of this fall. Review of the neurological checks found the following blood pressures recorded: - [DATE] at 9:30 p.m. ,[DATE] - [DATE] at 10:00 p.m. ,[DATE] - [DATE] at 10:30 p.m. ,[DATE] - [DATE] at 11:30 p.m. ,[DATE] - [DATE] at 12:30 a.m. ,[DATE] - [DATE] at 1:30 a.m. ,[DATE] - [DATE] at 2:30 a.m. ,[DATE] - [DATE] at 6:30 a.m. ,[DATE] (Note: Some physicians consider blood pressure too low only if it causes noticeable symptoms, such as dizziness. Some define low blood pressure as readings lower than 90 mm Hg (millimeters of mercury) systolic or 60 mm Hg diastolic and only one number needs to be in the low range for the individual's blood pressure to be considered lower than normal.) Further review of the record found another change in condition nursing note dated 9:14 a.m. on [DATE]. This change in condition note indicated that Resident #139 had another fall in her room, which was unwitnessed. Her blood pressure at 8:00 a.m., which was the approximate time of the fall, was recorded as ,[DATE]. The note also indicated the resident continued to be confused. The physician was again notified of this fall, but the record contained no evidence that he was made aware of the resident's multiple low blood pressure readings. The facility continued neurological checks on the resident and obtained the following blood pressure reading following this fall: - [DATE] at 8:30 a.m. ,[DATE] - [DATE] at 9:30 a.m. ,[DATE] - [DATE] at 10:00 a.m. ,[DATE] - [DATE] at 11:00 a.m. ,[DATE] - [DATE] at 12:00 p.m. ,[DATE] - [DATE] at 1:00 p.m. ,[DATE] - [DATE] at 5:00 p.m. ,[DATE] - [DATE] at 9:00 p.m. ,[DATE] - [DATE] at 1:00 a.m. ,[DATE] - [DATE] at 5:00 a.m. ,[DATE] - [DATE] at 9:00 a.m. ,[DATE] - [DATE] at 1:00 p.m. ,[DATE] - [DATE] at 4:00 p.m. ,[DATE] - [DATE] on the 7:00 a.m. to 3:00 p.m. shift (actual time not documented in the record) the resident's blood pressure was ,[DATE]. - [DATE] on the 3:00 p.m. to 11:00 p.m. shift (actual time not documented in the record) the resident's blood pressure was ,[DATE]. - [DATE] on the 11:00 p.m. to 7:00 a.m. shift (actual time not documented in the record the resident's blood pressure was ,[DATE]. There was no evidence to indicate Resident #139's attending physician was notified of any of her episodes of [MEDICAL CONDITION], which began on [DATE] and continued until [DATE] with the exception of 9:30 a.m. on [DATE] until 9:00 p.m. on [DATE], when the resident's blood pressures were not hypotensive. The facility continued to administer her prescribed medications, which lower blood pressure, until [DATE] at 11:00 a.m. It was at that time a change in condition note was completed and indicated the resident had episodes of dizziness and loss of balance and [MEDICAL CONDITION]. Her blood pressure at that time was recorded as ,[DATE]. When notified of this, the physician gave the following order (typed as written): Orthostatic (blood pressures) q (every shift) (laying, sitting, and standing) for three (3) days. (Orthostatic [MEDICAL CONDITION] is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position.) An interview with Resident #139's family member at 3:10 p.m. on [DATE] revealed that Resident #139 never had any trouble with her blood pressure and she was not sure why she was receiving two (2) blood pressure medications. She indicated she had discussed this with staff, but she did not think the facility had addressed this. During an interview with the Director of Nursing (DON) at 9:31 a.m. on [DATE], evidence the facility had notified the physician about Resident #139's [MEDICAL CONDITION] prior to [DATE] was requested. She indicated that the physician had seen her on three (3) occasions during her stay here. She stated that on [DATE] he saw her related to her falls. Review of the physician progress notes [REDACTED]. When he saw her on [DATE], he completed her history and physical, but did not note what her vital signs were upon his visit, nor was there mention of anything related to [MEDICAL CONDITION]. However, her episodes of [MEDICAL CONDITION] had not started by that date. The physician again saw the resident on [DATE] and noted that she had two (2) unwitnessed falls, which was the reason for his visit. The vital signs section of his progress note was blank. The physician indicated they would encourage the resident to use her call button and for her to have no unsupervised transfers. The physician's final visit with the resident on [DATE], was after he was contacted by staff and made changes to the resident's drug regimen regarding the management of her hyper/[MEDICAL CONDITION]. After review of the physician's progress notes with the DON, she stated she would see if she could find any other information that would indicate the physician was notified of the resident's [MEDICAL CONDITION] prior to [DATE]. At 11:43 a.m. on [DATE], the DON confirmed that she could find no evidence the physician was notified of Resident #139's [MEDICAL CONDITION] prior to [DATE]. | 2020-02-01 |