cms_WV: 4060
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4060 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 282 | D | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, staff interview, and policy review, the facility failed to implement the care plan for two (2) of thirty-two (32) Stage 2 sampled residents. The facility did not implement Resident #139's care plan related to the treatment of [REDACTED].#153's care plan in regards to pain management. Resident identifiers: #139 and #153. Facility Census: 100. Findings include: a) Resident #139 1. [MEDICAL CONDITION] 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]. A review of Resident #139's care plan found the following focus statement, (Residents Name) is at risk for complications related to a [DIAGNOSES REDACTED]. The goal associated with this focus statement was, Resident's blood pressure will remain within baseline parameters through next review. This goal had a target date of [DATE]. The goals associated with this problem statement included, Administer Meds (medications) as ordered and assess for effectiveness and side effects and report abnormalities to physician and obtain vital signs as ordered and report abnormalities to physicians. 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]. A change in condition nursing note written at 9:40 p.m. on [DATE], 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 ,[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. Again the physician was notified of this fall, but the record contained no evidence that he was made aware of the residents multiple blood pressure readings which were in the [MEDICAL CONDITION] range. The facility continued neurological checks on the resident and obtained the following blood pressure reading following this fall: - [DATE] 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 too [DATE] as directed by the resident's care plan. b) Resident #153 A review of Resident #153's medical record at 10:17 a.m. on [DATE] found a physician's orders [REDACTED]. This order had a start date of [DATE] and was a current order at the time of this review. Review of the facility's Pain Management Policy titled, Pain Management, with an effective date of [DATE], a review date of [DATE], and a revision date of [DATE], found it contained the following under, Practice Standards: - 5. If PRN medications are given, document on the back of the MAR or on the PRN pain management flow sheet . - 8. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. - Document: -- 8.1 Effectiveness of PRN medications. -- 8.2 Ineffectiveness of routine or PRN medications including interventions, follow - up, and physician/mid level provider notification. A review of Resident #153's care plan found a focus statement of, The resident is at risks for alterations in comfort related to chronic pain, Dx (diagnosis) of [MEDICAL CONDITION]. The goal related to focus statement was, Resident will achieve acceptable level of pain control aeb (as evidenced by): no verbal complaints of pain or non verbal complaints of pain such as crying, moaning, grimacing, guarding agitation or resisting care daily through next review. The interventions related to this goal included, Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects and report to physician if indicated. Review of Resident #153's MAR beginning on [DATE] through present found the following dates on which the resident received a PRN pain medication and the effectiveness of the medication was not assessed. The following dates are dates in which the [MEDICATION NAME] ,[DATE] was signed out on the Controlled Substance Log for Resident #153, but was not documented on the MAR or the nurses' notes that this medication was administered and/or its effectiveness in treating Resident #153's pain: (The dates are the same, but the times are different. One set of dates and times include when the medication was signed out both on the MAR and the controlled substance log, the other set of dates and times are the times when the medication was just signed out on the controlled substance log and not recorded on the MAR. However, on all occasions the resident received a PRN pain medication and the staff did not assess its effectiveness.) - [DATE] at 9:30 a.m. - [DATE] at 2:00 a.m. and 6:00 p.m. - [DATE] at 2:00 p.m. and 8:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 1:00 p.m. and 6:00 p.m. - [DATE] at 8:00 p.m. - [DATE] at 12:00 a.m., 6:00 a.m., and 2:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 7:00 a.m., 12:00 p.m., and 9:00 p.m. - [DATE] at 2:00 a.m., 7:00 a.m., 1:00 p.m., and 9:00 p.m. - [DATE] at 5:00 a.m., 2:00 p.m., and 9:00 p.m. - [DATE] at 2:00 a.m., 6:00 a.m., and 9:00 p.m. - [DATE] at 4:00 a.m. - [DATE] at 8:00 a.m. and 10:30 p.m. - [DATE] at 8:00 a.m. and 1:00 p.m. - [DATE] at 12:00 a.m., 7:00 a.m., 1:00 p.m., 6:30 p.m., and 11:00 p.m. - [DATE] at 5:00 a.m., 2:00 p.m., and 9:00 p.m. - [DATE] at 9:00 a.m. and 6:00 p.m. - [DATE] at 5:00 a.m., 12:30 p.m., and 9:00 p.m. - [DATE] at 5:00 a.m., 9:00 a.m., and 9:00 p.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m., 9:00 a.m., 2:00 p.m., and 10:00 p.m. - [DATE] at 9:00 a.m., 2:00 p.m., and 9:00 p.m. - [DATE] at 6:00 a.m. - [DATE] at 1:00 a.m., and 6:00 a.m. - [DATE] at 5:00 a.m. - [DATE] at 5:00 a.m., and 9:00 p.m. - [DATE] at 6:00 a.m., 2:00 p.m. and 6:00 p.m. - [DATE] at 5:00 a.m., 9:00 a.m., 2:00 p.m., and 9:00 p.m. - [DATE] at 6:00 a.m., and 9:00 p.m. - [DATE] at 9:30 p.m. - [DATE] at 8:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 10:00 a.m. - [DATE] at 9:00 a.m., 3:00 p.m., and 9:00 p.m. - [DATE] at 5:00 a.m. - [DATE] 2:00 p.m. and 9:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 2:00 (did not specify a.m. or p.m.) - [DATE] at 2:00 p.m. - [DATE] at 6:00 p.m. - [DATE] at 11:00 p.m. - [DATE] at 2:00 p.m. and 9:00 p.m. - [DATE] at 6:00 a.m. - [DATE] at 5:00 p.m. - [DATE] at 8:00 p.m. - [DATE] at 10:30 p.m. - [DATE] at 2:00 p.m. - [DATE] at 10:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 6:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 3:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 2:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 1:00 a.m. - [DATE] at 8:00 p.m. and - [DATE] at 12:30 p.m. The following are the dates where the medications were signed out of the controlled substance log and the MAR, but nursing staff still failed to determine if the PRN pain medication was effective in controlling Resident #153's pain: - [DATE] at 5:00 a.m., 11:00 a.m., and 6:00 p.m. - [DATE] at 8:00 a.m. and 1:00 p.m. - [DATE] at 7:00 a.m., 1:00 p.m. and 7:00 p.m. - [DATE] at 10:00 a.m. and 4:00 p.m. - [DATE] at 2:00 a.m., 8:00 a.m., and 11:00 p.m. - [DATE] at 5:00 a.m. and 11:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 5:00 a.m., and 9:00 a.m. - [DATE] at 1:00 a.m., 6:00 a.m., and 10:00 p.m. - [DATE] at 5:00 a.m. and 10:30 a.m. - [DATE] at 5:00 a.m. and 11:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 4:00 a.m., 1:00 p.m., and 11:00 p.m. - [DATE] at 1:00 a.m., 2:00 p.m., and 8:00 p.m. - [DATE] at 5:00 a.m., 12:00 p.m., and 9:00 p.m. - [DATE] at 7:00 a.m., 1:00 p.m., and 7:00 p.m. - [DATE] at 12:00 a.m. - [DATE] at 9:00 p.m. - [DATE] at 11:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 9:00 a.m. - [DATE] at 5:00 a.m., 9:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m. and 8:00 p.m. - [DATE] at 5:00 a.m., 9:00 a.m., and 9:00 p.m. - [DATE] at 6:00 a.m. and 2:00 p.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 6:00 a.m. - [DATE] at 9:00 p.m. - [DATE] at 6:00 a.m., and 2:00 p.m. - [DATE] at 5:00 a.m., 2:00 p.m. and 9:00 p.m. - [DATE] at 12:00 a.m., and 6:00 a.m. - [DATE] at 6:00 a.m. and 2:00 p.m. - [DATE] at 5:00 a.m. and 11:00 a.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] at 1:00 p.m. and 7:00 p.m. - [DATE] at 6:00 a.m. and 11:00 a.m. - [DATE] at 5:00 a.m. and 11:00 a.m. - [DATE] at 6:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 5:00 a.m. and 8:30 a.m. - [DATE] at 5:00 a.m. and 9:00 a.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 9:00 a.m., 2:00 p.m., and 10:30 p.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m. - [DATE] at 5:00 a.m., 10:00 a.m., and 8:00 p.m. - [DATE] at 5:00 a.m. and 8:00 p.m. - [DATE] at 5:00 a.m. and 10:00 p.m. - [DATE] at 9:00 a.m., 2:00 p.m. and 9:00 a.m. - [DATE] at 7:00 a.m. and 8:00 p.m. - [DATE] at 1:00 p.m. - [DATE] at 5:00 a.m., 2:00 p.m. and 9:00 p.m. - [DATE] at 5:00 a.m. and 8:00 p.m. - [DATE] at 6:00 a.m. - [DATE] at 9:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 6:00 a.m., 2:00 p.m. and 7:00 p.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] at 8:00 a.m., 10:00 a.m. and 9:00 p.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] AT 6:00 a.m. - [DATE] at 9:00 a.m. and 9:00 p.m. - [DATE] at 6:00 a.m., 2:00 p.m. and 9:00 p.m. - [DATE] at 6:00 a.m. and 1:00 a.m. - [DATE] 12:00 a.m. and 2:00 p.m. - [DATE] at 7:00 a.m. - [DATE] at 6:00 a.m., 10:00 a.m., 3:00 p.m., and 8:00 p.m. - [DATE] at 7:00 a.m., 2:00 p.m., and 8:00 p.m. - [DATE] at 9:00 a.m. - [DATE] at 1:30 a.m. - [DATE] at 7:30 a.m. - [DATE] at 8:00 p.m. - [DATE] at 3:00 p.m. - [DATE] at 1:00 p.m. - [DATE] at 5:00 a.m. and 9:00 p.m. - [DATE] at 6:00 a.m. - [DATE] at 8:15 a.m. - [DATE] at 6:00 a.m. - [DATE] at 2:00 a.m. - [DATE] at 9:00 p.m. - [DATE] at 8:00 p.m. - [DATE] at 8:00 p.m. - [DATE] at 9:00 p.m. - [DATE] at 7:00 p.m. - [DATE] at 8:30 a.m. - [DATE] at 9:00 p.m., and - [DATE] at 6:00 a.m. Review of the nursing progress notes from [DATE] through the present found no evidence the resident's pain was reevaluated after the administration of the PRN pain medication on the identified dates. An interview with the DON at at 1:13 p.m. on [DATE] confirmed that the nurses who administer the PRN pain medication should evaluate its effectiveness on the MAR in the spaces provided to do so. She indicated the nurses should mark a Y for Yes and an N for No and if it was not completed on the MAR and not in the nurses' notes, then she would have to assume it was not done. She indicated that beginning in (MONTH) (YEAR) they are implementing a new pain management flow sheet and that will hopefully remedy this problem. The instances in which the medication was signed out on the controlled substance log, but not documented in the progress notes or on the MAR, were reviewed with the DON on [DATE] at 6:30 p.m. She stated if she found anything in the resident's record that showed where these were documented as administered, she would provide it. As of the time of exit on [DATE] at 8:30 p.m., no additional information was provided. | 2020-02-01 |