cms_WV: 7504
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7504 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 309 | D | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of twenty-one (21) Stage 2 sample residents. The facility did not routinely assess Resident #57, who was unable to verbally communicate, for pain. The facility failed to monitor oxygen saturations for Resident #21 and failed to ensure the resident was properly positioned for a nebulizer treatment. In addition, the facility treated the resident with medication for anxiety, instead of assessing the resident for the causal factors related to anxiety. Resident identifiers: #57 and #21. Facility census: 113. Findings include: a) Resident #57 Review of this resident's medication administration records (MARs) for April 2013 revealed the resident received frequent doses of Tylenol on an as needed (PRN) schedule. She received seventeen (17) doses in the month of April, ranging in time from 7:00 a.m. to 8:00 p.m. The medication was then scheduled for twice a day, in addition to the as needed regimen. Pain assessment flow sheets noted assessments from 04/02/13 through 04/30/13. In an interview, a licensed practical nurse (LPN) indicated residents were to be assessed for pain daily. A notebook, kept at the nurses' station, noted which shift was to evaluate pain as a routine assessment, and note it on the pain assessment flow sheet. The LPN looked at the book and said day shift would have documented daily on Resident #57. She said pain would be noted either on the pain flow sheet or on the MAR. Review of the MAR indicated [REDACTED]. The LPN confirmed the daily assessments were not completed according to facility policy. Further review of the medical record, revealed daily assessments were also not completed after the resident began receiving pain medication on a routine basis. An interview with Employee #85 (LPN), on 06/11/13 at 10:52 a.m., revealed the resident had pain in her back and sometimes a headache. Review of the June 2013 MARs indicated no PRN doses were administered since the pain medication was scheduled. The nurse said the resident complained of pain that morning (06/11/13) when the LPN raised the head of the bed. At that time, the resident was observed sitting in the hallway outside the nurses' station, leaning slightly to the left. The nurse said the resident would sometimes lean in her chair if she had pain. Employee #55 (RN) confirmed an accurate assessment of pain could not be determined. The RN said the resident was not able to to express herself and pain could not be rated on a 0-10 pain scale. She indicated staff needed to document grimacing/facial expressions. She reviewed the medical record and confirmed this had not been done. An interview with the pharmacist consultant, on 06/11/13 at 2:00 p.m., revealed he reviewed pain medication over a two (2) month period to evaluate effectiveness and irregularities. He said he had reviewed the pain flow sheets and was aware staff had not accurately completed the pain flow record. He said he had discussed the issue with the nurses and with the director of nursing (DON), but the problem continued. b) Resident # 85 Review of the medical record on 06/12/13 at 3:03 p.m., revealed Resident #85 had a [DIAGNOSES REDACTED]. During an interview with Employee #136 (LPN), she said the resident would become short of breath, restless, and remove his oxygen. She said he would position himself toward his left side. Employee #85 (LPN) agreed with this information. A physician's orders [REDACTED]. In addition, his oxygen saturation (SpO2) was to be checked as needed for dyspnea (shortness of breath). Further review of the medical record revealed Resident #85 received [MEDICATION NAME] on a PRN schedule for seven (7) of eleven (11) days in June 2013; and eighteen (18) of thirty-one (31) days in May. The nurses said his anxiety was related to his [MEDICAL CONDITION]. Review of the MARs and treatment administration records (TARs) for April, May, and June 2013, revealed no entries for an SpO2. Employee #85 confirmed no evidence was present in the medical record to indicate the resident's oxygen saturation was evaluated prior to administering the [MEDICATION NAME]. Observation of the resident, on 06/13/13 at 8:15 a.m., revealed the resident was receiving a nebulizer treatment. His bed was in semi-fowlers position (about 45 degrees) and he was slumped down in the bed. He was leaning toward the left, holding onto the sidebar. His breathing was fast and he was using his accessory muscles. His abdomen was heaving in and out. Employee #45 (LPN) was interviewed. She said she had placed a breathing treatment on the resident because he was short of breath. Upon questioning, she confirmed his positioning was not conducive to adequate air exchange. She requested a nursing assistant pull him up in bed. The NA (Employee #117) said, He can pull himself up, that's why he has the sidebars. The RN confirmed and the resident verified, he could not reposition himself with the head of the bed elevated. The RN lowered the head of the bed and the NA moved Resident #85 up in bed. The head of the bed was then elevated to an upright position. When asked if the positioning was more effective, the resident did not speak, but gave a thumbs up. Interviews with staff and review of the medical record provided no evidence staff assessed the resident for anxiety related to [MEDICAL CONDITION] (lack of oxygen). Symptoms of anxiety were treated with [MEDICATION NAME] without assessing whether other factors were related to the resident's anxiety, such as shortness of breath due to positioning resulting in low oxygen saturations, that might be treated without the use of [MEDICATION NAME]. | 2017-04-01 |