cms_WV: 4793
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4793 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 309 | D | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental or psychosocial well-being for one (1) of five (5) residents reviewed for unnecessary medications. The facility failed to adequately assess and monitor a resident who experienced an exacerbation of [MEDICAL CONDITIONS]. Resident identifier: 96. Facility census: 81. Findings include: a) Resident #96 During a Stage 1 interview, on 01/11/16 at 1:10 p.m., Resident #96 expressed he utilized an inhaler for shortness of breath. The resident related, I had to give my inhaler up. When you need it, you just smother. Here you have to ask for it .I don't (do not) like it at all. Sometimes I go up there and there is no one at the desk at all, and I smother and am uncomfortable, and it makes me mad. I am not mental. Upon inquiry, the resident related he had not discussed it with the physician, but I talk to the nurse all the time. They can't (cannot) do anything unless he tells them. Don't (Does not) make sense to me. Sometimes I go out there and there is two (2) of them, and they are busy doing other things and had to wait. The resident related he always had one on me, wherever I went, I had it, but they took it away from me here. The resident related he had been in the facility about two (2) months. Another interview with Resident #96, on 01/13/16 at 8:31 a.m., revealed his status as I'm (I am) fair. I'd (I would) say I am fair. The resident further added, I just can't (cannot) seem to connect here. The resident related he would go to the hospital, and sometimes had to wait a long time, but would sit and converse with other men. The resident said he was able to talk about his feelings and they would give him nerve pills. The resident related he was unsure of what the facility administered him, but indicated he used inhalers and took a blood thinner medication to keep him from having a [MEDICAL CONDITION]. It beats real fast. Review of the minimum data set (MDS) with the admission minimum data set (MDS) with an assessment reference date (ARD) of 11/16/15, on 01/12/16 at 2:31 p.m. revealed in section I, a [DIAGNOSES REDACTED]. A brief interview for mental status (BIMS) score in section C indicated the resident was moderately cognitively impaired. A pharmacy recommendation, dated 12/08/15 indicated the resident requested the addition of [MEDICATION NAME] and [MEDICATION NAME] for memory. An activity assessment, dated 11/11/15 indicated Resident #96 was oriented to person, place, time, family, season and year. Review of the care plan, on 01/19/16 at 3:41 p.m., revealed an alteration in cognition and communication and interventions included attempting to include the resident in his own self-care duties to improve self-care ability, autonomy of care, breathing treatments, and inhalers due to shortness of breath and promote opportunities to participate in decisions regarding care. The care plan revealed the resident had an exacerbation of [MEDICAL CONDITIONS], and indicated Resident #96 was treated with antibiotic therapy, a [MEDICATION NAME] dose pack (steroid therapy), and inhalation treatments via nebulizer. It noted staff should notify the physician of a decreased SAO2 (direct measurement of the saturation of hemoglobin with oxygen in arterial blood.) Further review of the medical record, on 01/19/16 at 5:28 p.m. revealed no evidence of SAO2 (percentage of oxygen saturation of arterial blood) results in the weight/vital signs section of the electronic medical record (EMR). Medication sheets, reviewed for the months of November, (MONTH) and (MONTH) revealed no evidence the resident had received a dose of [MEDICATION NAME] HFA (prescription inhaled medicine used to treat [MEDICATION NAME]), although an interview with Licensed Practical Nurse #101 on 01/20/16 at 2:30 p.m. related the resident asked for, and received the medication, usually in the evenings. physician's orders [REDACTED]. Other medications related to [MEDICAL CONDITION] included [MEDICATION NAME] inhaler 18 micrograms (mcg) one time a day, [MEDICATION NAME] HFA Aerosol Solution 108 (90) base mcg/act ([MEDICATION NAME] sulfate HFA) two (2) puffs inhale orally every six (6) hours as needed for [MEDICAL CONDITION]; [MEDICATION NAME] aerosol (medication used to prevent broncospasm in people with asthma or [MEDICAL CONDITIONS] 160-4.5 mcg ([MEDICATION NAME]-[MEDICATION NAME]) two (2) puffs inhale orally twice a day. The facility policy and procedure manual located at the nurse's station was reviewed on 01/13/16 at 9:20 a.m. The policy contained nursing tips for F329 which indicated the nurse should monitor, assess, and document the effectiveness of a medication regime. Progress notes, reviewed on 01/20/16 at 2:30 p.m., with Registered Nurse #18 and LPN #101, revealed no evidence the facility had adequately monitored the residents lung sounds and/or vital signs. The notes indicated on: --01/08/16 orders were received for a chest x-ray was ordered due to congestion and a productive cough, a sputum culture, and a flu swab for malaise (feeling of general discomfort) and fatigue. The sputum expectorated noted to be green mucus like texture. Complaints of malaise at this time, vital signs obtained with a temperature of 97.9 axillary, Pulse 102 ) No assessments were noted for 01/09/16, 01/10/15, 01/11/16, 01/12/16, 01/13/16, or 01/14/16. --01/15/16 a physician's orders [REDACTED]. New orders were received for [MEDICATION NAME] 875-125 milligrams (mg), a [MEDICATION NAME] dose pack, [MEDICATION NAME] (nebulizer breathing treatments), and every eight (8) hours for seven (7) days for exacerbation of [MEDICAL CONDITION] ([MEDICAL CONDITION].) No evidence of a [MEDICAL CONDITION] (lung) assessment was noted on 01/16/16, 01/17/16, 01/8/16, or 01/19/16. --An entry dated 01/20/16 indicated Lung sounds noted to be wheezing . The assistant director of nursing (ADON) #34 on 01/20/2016 at 4:22 p.m. related nurses should have completed assessments which included lung sounds, SPO2 (indirect measurement of the saturation of hemoglobin with oxygen in arterial blood. Measurement is taken using a finger probe or ear sensor) (not required but nursing measure), and noted a cough productive/non-productive, congestion when there was a change in condition or as long as the resident received antibiotic therapy. The ADON confirmed the facility had not adequately assessed the resident's respiratory status. | 2019-07-01 |