cms_WV: 6951
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6951 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 329 | D | 0 | 1 | WVZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview with the medical director, and staff interview, the facility failed to ensure residents drug regimens were free of unnecessary drugs. This was found for two (2) of eleven (11) residents reviewed for unnecessary medications. Resident #65 received [MEDICATION NAME] on an as needed (PRN) basis without sufficient identification of the behaviors to be monitored or evidence of behavioral interventions. Resident #18 received [MEDICATION NAME] (an antipsychotic medication and [MEDICATION NAME] (an antidepressant medication), without a gradual dosage reduction. Resident #18 also did not have laboratory testing as recommended by the pharmacist, to monitor the use of [MEDICATION NAME] (an anticonvulsant). The facility also failed to inform the resident/responsible party of the benefits/risks of medications. Resident identifiers: #65 and #18. Facility census: 59. Findings include: a) Resident #65 On 06/24/13 at 1:30 p.m., a review of the medical record was conducted. The physician's orders [REDACTED].#65 had been ordered [MEDICATION NAME] 0.5 mg orally or IM (intramuscular) every four (4) hours as needed (PRN) with no [DIAGNOSES REDACTED]. In a physician's progress note, dated 04/03/13 at 15:58 (3:58 p.m.), in the section PLAN, it was noted Continue p.r.n. medicines . [MEDICATION NAME] IM or p.o. (by mouth) for extreme agitation and restlessness. The Medication Administration Record [REDACTED]. The Psychoactive Drug Monthly Flow Record, dated April 2013 in Section I Specific Behaviors indicated the monitoring of refusing care, increased agitation and aggression. The flow record documented no behaviors or side effects from 04/10/13 through 04/15/13. The days prior to this documentation and the days following were blank. A further review of Resident #65's MARs noted the following: On 03/28/13 at 8:26 a.m., [MEDICATION NAME] 0.5 mg was administered orally for anxiety. No evidence was discovered as to the reason the medication was given. There was no indication what constituted anxiety and how this was affecting the resident. On 03/30/13 at 13:35 (1:35 p.m.), [MEDICATION NAME] 0.5 mg was administered orally for other. The Patient Progress Notes indicated at 14:22 (2:22 p.m.), Disruptive Behavior: Going into other residents' room and going through their drawers. When tried to redirect, Resident became resistant with leaving room. Resident then began taking drinks off tray in hallway and started dumping them. When tried to take Ensure (nutritional supplement) that she spilled, became combative. Gave PRN [MEDICATION NAME] at 1325 (1:25 p.m.) No further evidence was discovered of other non-pharmacological interventions. On 04/01/13 at 18:22 (6:22 p.m.), [MEDICATION NAME] 0.5 mg was administered orally for agitation. A review of the patient progress notes during this time frame did not reveal any documentation as to why the [MEDICATION NAME] was given and any associated resident behaviors. Again, at 22:27 (10:27 p.m.) Resident #65 was given [MEDICATION NAME] 0.5 mg orally for anxiety. A review of the patient progress notes for 04/01/13 at 22:28 (10:28 p.m.) revealed the following nurse's note, medicated with PRN [MEDICATION NAME] 0.5 mg for increased anxiety; nursing interventions unsuccessful; will monitor. The nurses' notes provided no further description of the resident behaviors or the type of nursing interventions that were provided. On 04/05/13 at 8:15 a.m., [MEDICATION NAME] 0.5 mg administered orally for anxiety. The nurse's notes at 15:39 (3:39 p.m.) stated, Resident resting in bed at this time. This a.m., resident was sitting in hallway and started crying. Unable to tell staff what was wrong, just said 'I don't know why I'm crying.' [MEDICATION NAME] given as per PRN order. Thirty minutes later resident was no longer anxious. No anger outbursts. (Family member) called and updated on care and spoke with resident also. No non-pharmacological interventions were noted prior to administering [MEDICATION NAME]. 04/06/13 at 22:36 (10:36 p.m.)., [MEDICATION NAME] 0.5 mg administered orally for anxiety. The patient progress notes stated (typed as typed in the electronic medical record (EMR) Disruptive behavior: acting out verbally; yelling about reindeer; unable to calm down with nursing nursing interventions; medicated with PRN [MEDICATION NAME] 0.5mg; will monitor for success. An additional nurse's note, on 04/06/13 at 16:28 (4:28 p.m.) noted (typed as typed in the EMR) Resident has been up in chair most of day. - appitite remains good. Started hollaring out for her parents . 'they're probably out running around with the wrong people.' Then started hollaring for her 'no good boys of mine'. Started to get aggitated. [MEDICATION NAME] given per prn order. Resident sitting out in hall at present . There was no indication what nursing interventions were tried with this resident. On 04/07/13 at 13:09 (1:09 p.m.) and at 17:43 (5:43 p.m.), [MEDICATION NAME] 0.5 mg administered orally for anxiety. The nurse's note, at 15:07 (3:07 p.m.) stated (typed as typed into EMR) yelling for 'HELP', confused, and anxious. Given PRN [MEDICATION NAME]. There was no indication whether non-pharmacological interventions were attempted prior to giving the [MEDICATION NAME]. In the Controlled Medication Utilization Record, for Resident #65, an additional dose of [MEDICATION NAME] was noted on 04/07/13 at 1300 (1:00 p.m.). The MAR indicated [REDACTED]. There was no evidence in the nurses' notes to indicate the reason for giving the [MEDICATION NAME]. An interview with the director of nursing (DON) was conducted on 06/24/13 1:50 p.m The DON was asked if non-pharmacological interventions were to be tried prior to the administration of the PRN [MEDICATION NAME]. The DON responded Yes. Staff need to try food and fluids, toileting, and getting out of bed. After the DON reviewed the evidence in the patient progress notes and nurses' notes, she agreed no specific (non-pharmacological) interventions were consistently documented. The DON agreed there were times when there was no documentation of why the [MEDICATION NAME] had been given to Resident #65. When asked about the use of the monthly behavior monitoring forms, the DON explained the forms were implemented during a complaint survey in April 2013 because evidence could not be found of the documentation of behaviors and a reason for the administration of a PRN anti-anxiety meds. The DON confirmed the information was lacking regarding non-pharmacological nursing interventions that were attempted and the lack of specific behaviors as is required for the monitoring of unnecessary medications. b) Resident #18 1) During a Stage 1 observation, on 06/19/13 at 8:30 a.m., Resident #18 was observed walking from the dining room to her room, which was located at the end of the hallway. She had a shuffling, unsteady gait, and tremor of her hands. She utilized the handrails to stabilize herself while walking. During a medical record review for unnecessary medications, on 06/19/13 at 12:36 p.m., it was noted the resident received [MEDICATION NAME] and [MEDICATION NAME], which are [MEDICAL CONDITION] medications. The pharmacy recommendations were reviewed, and revealed the pharmacist had made recommendations which had been declined by the physician. A clinical rationale, specific to the resident, was not provided. Review of the behavior monitoring sheets indicated the resident had not been exhibiting the behaviors identified as indicators for receiving the medication. The pharmacist also noted the resident had not been exhibiting behaviors and had recommended gradual dose reductions. Pharmacy recommendations were noted as follows: On 11/13/12, the pharmacist had recommended a gradual dose reduction of [MEDICATION NAME] due to an increase of tremors, but there was no evidence of hallucinations or paranoia. The physician declined with the rationale the medication was working. However, a gradual dose reduction had been initiated on 01/18/12, and was successful. Also noted on the 01/18/12 recommendation, the physician's response for accepting the recommendation was, You know, I didn't start this drug in the first place, I don't think. A pharmacy review, completed on 07/25/12, indicated the resident was receiving [MEDICATION NAME] and [MEDICATION NAME]. The pharmacy recommendation noted the resident had a [DIAGNOSES REDACTED]. It noted [MEDICATION NAME] may antagonize [MEDICATION NAME]'s effects in the treatment of [REDACTED]. If continued, a risk versus benefits, indicating it continued to be a valid therapeutic intervention for Resident #18, needed to be completed. The physician declined the recommendation, noting the medications were ordered by a neurologist. Employee #98 a licensed practical nurse (LPN), who reviewed pharmacy recommendations and ensured compliance, and Employee # 94, a registered nurse (RN) and nurse manager of the long term care unit, were interviewed on 06/20/13 at 8:50 a.m. They confirmed a risk versus benefits had not been completed. They also confirmed the resident had not seen the neurologist for further intervention. Another interview with Employee #98 (LPN), on 06/20/13 at 11:20 a.m., revealed the facility did not communicate risk/benefits of medications to residents, mdedical powers of attorney, or surrogates. The LPN said the pharmacist told her they did not complete the task either. During another interview with Employee #98, on 06/20/13 at 1:20 p.m., she confirmed risks and benefits were not reviewed with the Resident #18, or her family, verbally or in writing Another pharmacy recommendation, dated 06/22/13, revealed a recommendation to decrease the [MEDICATION NAME], and noted an annual review was due. Resident #18's most recent minimum data set (MDS) indicated minimal depression symptoms. The physician declined the recommendation noting a reduction may impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. The physician's rationale to substantiate his concern was noted as Again. 2) A pharmacy recommendation for Serum [MEDICATION NAME] and [MEDICATION NAME] concentrations was initiated on 03/14/13. The rationale was a manufacturer's recommendation because [MEDICATION NAME] is actively metabolized to [MEDICATION NAME]. The physician's declination for obtaining labs was noted as, I didn't start her on this. During an interview with Employee #98 (LPN) and Employee #94 (RN/nurse manager), they confirmed the laboratory tests had not been completed. The physician failed to provide a clinical rational, specific to Resident #18, for the continuation of [MEDICATION NAME] or [MEDICATION NAME]. The physician also failed to provide a clinical rationale related to the declination of laboratory serum (blood) drug levels related to medications. A review of the pharmacy regimen review, revealed no recommendations related to [MEDICATION NAME], or [MEDICATION NAME], between November 2012 and June 2013. An interview with the medical director, Employee #269, on 06/24/13 at 7:50 a.m., revealed [MEDICAL CONDITION] medications are reviewed monthly. He said recommendations were made for gradual dose reductions every three (3) months. He indicated the process was recently initiated. The medical director reviewed the pharmacy recommendations for Resident #18. He confirmed sound clinical rationale was not provided. Employee #269 said he had addressed pharmacy recommendations in physician staff meetings. The medical director said he knew it was a concern, but was not aware of the specific responses made by the physician. | 2017-09-01 |