cms_WV: 7026
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
7026 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 514 | B | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of clinical records for one (1) of twenty (20) residents reviewed in Stage 2 of the survey. A physician's response to a pharmacy recommendation was not transcribed to the medical record. Resident identifier: #99. Facility census: 73 Findings include: a) Resident #99 On 08/21/13 at 9:00 a.m., a medical record review was conducted for Resident #99. Review of the Pharmacy consultation report, dated 04/04/13, revealed a recommendation to clarify order to read [MEDICATION NAME] for depression. The attending Physician documented and signed the record on 04/10/13 writing, ok to be for depression. A review of the Medication Administration Records (MAR), dated June, July and August 2013, revealed the MAR indicated [REDACTED]. Employee #13, the Administrator (NHA), provided the requested copies of the attending physician's orders [REDACTED].#99's [DIAGNOSES REDACTED]. Also, the MARs for April and May 2013 had the [DIAGNOSES REDACTED]. At 11:20 a.m. on 08/21/13, an interview was conducted with the NHA. She confirmed an order for [REDACTED]. On 08/21/13 at 11:40 a.m., an interview was conducted with Employee #23, the Director of Nursing (DON). She stated the procedure the facility was supposed to follow regarding pharmacy recommendations was to give the recommendation to the doctor on his visit to the facility. After his signature was obtained, it was to be signed by the DON or the nurse on duty. A physician's orders [REDACTED]. The pharmacy recommendation sheet was then to be placed in the medical record for the pharmacist to review on the next monthly visit. Employee #23 stated, There is not a written policy or procedure regarding this, it was like this when I came here and it has continued. | 2017-09-01 |