cms_WV: 4742
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4742 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 309 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to consistently assess, monitor and attempt to manage or prevent Resident #7's pain. For Resident #1 the facility failed to follow the physician's orders [REDACTED]. This was true for two (2) of eleven (11) resident's medical records reviewed for quality of care during a complaint survey, ending on 07/07/16. Resident identifiers: #7 and #1. Facility census: 113. Findings include: a) Resident #7 Record review on 07/06/16 at 8:30 a.m. found a sixty-four (64) year old female resident admitted to the facility on [DATE]. The resident was discharged from a hospital, to the facility, for rehabilitation following total bilateral knees arthroplasty on 05/19/16. Other [DIAGNOSES REDACTED]. The facility's nursing notes, upon admission, indicated the resident was alert and oriented and able to voice her needs. Less than twenty-four (24) hours later, on 05/25/16, at 2:02 p.m., the resident was discharged to the hospital. Admitting medications included: [MEDICATION NAME]/[MEDICATION NAME] 5/325 to be administered every 4 hours, as needed, for pain. The hospital discharge summary noted the resident received her last dose of the pain medication at 3:00 p.m. on the day of discharge (05/24/16). Review of the nursing notes found the following documentation: --At 10:30 p.m. on 05/24/16, the resident was refusing to have CMP machine (continuous passive motion machine used for knee joint recovery) placed on at this time, currently waiting on pain medication from pharmacy. Pharmacy request for pain medication was faxed at 7:00 p.m. --A nursing note written at 6:59 a.m. on 05/25/16 revealed the resident resting in bed at this time. Upon putting resident on bed pan noted a small opened area to her right buttocks. Pain medication given as ordered due to the complaint of pain. Resident is complaining of some discomfort at this time but refuses pain medications said she feels different as of last dose given at 3:00 a.m. It was noted the call bell within reach will continue to monitor. --A nursing note written at 1:50 p.m. on 5/25/16 revealed a small amount of bleeding on bandage after dressing change. The resident's husband was at the desk approximately 1:30 p.m. and stated resident has excess bleeding from surgical site on right knee and was very anxious and wanted to go to the hospital. Upon evaluation, resident was anxious, diaphoretic with shortness of breath), complaint of pain and swelling in knee and bleeding was noted on bandage and under knee on sheets. It was also noted the resident's temperature was 99.9 and using oxygen by way of a nasal cannula. The note further stated, the resident was bleeding from the nose and right knee surgical incision with labored breathing and lower extremity [MEDICAL CONDITION]. Physician was notified of change in condition and the resident was sent to the hospital. Review of the medication administration record (MAR), found the resident received only one (1) dose of the [MEDICATION NAME] at 3:00 a.m. on 05/25/16. There was no indication in the medical record the resident's pain was rated at this time and no follow up information, after one (1) hour to indicate if the medication was effective. Review of the physical therapy initial evaluation completed on 05/25/16, found the resident verbally stated she was experiencing pain. The resident rated her pain as a 9 out of 10 indicating severe pain in both knees. Nursing was notified of the resident's pain. The director of nursing (DON) interviewed at 10:52 a.m. on 07/06/16 verified [MEDICATION NAME]/[MEDICATION NAME] 5/325 was available in the facility's emergency medication box. The DON did not know why the nurse was awaiting delivery of the medication when the medication was available at the facility. The DON did say the pharmacy had to be contacted to supply a code to obtain the medication as the medication was a controlled substance. The physician would also need to be contacted for approval to dispense the medication. The DON verified the only dose of [MEDICATION NAME] given to the resident was at 3:00 a.m. on 05/25/16, according to the MAR. Interview with the physical therapist (PT) #37 at 2:10 p.m. on 07/06/16, verified she told nursing the resident was experiencing severe pain. Although her assessment did not include the time of the interview, PT #37 said she was in the resident's room right after breakfast, which she estimated to be around 9:15 a.m. to 9:30 a.m. on 05/25/16. At 4:00 p.m. on 07/06/16, Registered Nurse, (RN) #73, was interviewed. RN #73 was the author of the nursing note written at 10:30 p.m. on 05/24/16. Why asked why she did not obtain the pain medication, [MEDICATION NAME], from the emergency box, she replied, I did get pain medication from the emergency box. She reviewed the MAR and said, I guess I didn't write it down. RN #73 called the pharmacy who faxed verification a code was supplied to obtain the [MEDICATION NAME] from the emergency box. According to the fax information, verification was given at 11:03 p.m. on 05/24/16. RN #73 said she gave the medication shortly after she received the authorization code allowing her to obtain the medication from the facility's emergency supply. RN #73 said she did not follow up on the effectiveness of the medication because she went home at 11:30 p.m. on 05/24/16. At 4:30 p.m. on 07/06/16, the administrator was advised of the above interview with RN #73 and PT #37. She was asked if she could provide any information verifying the following: --Was [MEDICATION NAME] administered around 11:00 p.m. on 05/24/16? --Did staff follow up on the effectiveness of the pain medication given at 3:00 a.m. on 05/25/16? --Did staff follow up on the report of the resident's pain when reported by the PT on the morning of 05/25/16? --Did the facility attempt any non-pharmacological interventions to manage the resident's pain? At the close of the survey at 2:30 p.m. on 07/07/16, no further information had been provided. b) Resident #1 A review of the resident's medical record on 07/06/16 at 3:00 p.m. revealed there were physician orders [REDACTED]. This included do not weight orders dated for 06//12/16. Weight records were evaluated on 07/06/16 and it was found that weights continued for 7/1/16 even though there was do not weigh order. The weight was 126 lbs. On 07/07/16 at 9:45 a.m. with Employee #57 and Employee #111 revealed there was no evidence to support why the weights had continued with current physician's orders [REDACTED]. | 2019-07-01 |