cms_WV: 8205
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8205 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 280 | E | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to revise the care plans for four (4) of forty-six (46) sampled residents. Residents' care plans were not revised when they were receiving comfort care, [MEDICAL TREATMENT] interventions were not incorporated into the care plan, [MEDICAL CONDITION] were not addressed, interventions for the use of psychoactive medications were not established, and no interventions were put in place for a resident experiencing episodes of pain. Facility census: 115. Resident identifiers: #104, #17, #55, and #185. Findings include: a) Resident #104 Review of the medical record for Resident #104 found, on 04/26/12, the resident was placed on comfort measures only. Employee #39 (registered nurse) and Employee #16 (social worker) met with the resident's son and discussed his wishes for comfort care. The medical record identified Employee #39 as the person who updated the POST (physician's orders [REDACTED]. On 05/01/12, the physician discontinued all medications and added [MEDICATION NAME] related to pain. During an interview with Employee #17, on 05/16/12 at 10:15 a.m., it was confirmed that she and Employee #39 had discussed with the son his wishes and the care plan was not updated to reflect the changes in care. b) Resident #17 1) Suicidal ideation Review of the medical record found Resident #17 had stated to the facility on [DATE], I wish I had a gun, I'd shoot them both then shoot myself. On 05/21/12 at 1:48 p.m., Employee #2 (director of nursing) stated, She has said she was going to kill herself before. Back on 01/31/12, she was sent to the hospital then for psychiatric services. Review of the medical record found further documentation the resident had suicidal ideation on other occasions. On 02/10/12, Resident #17 told the nurse I don't care if I die. On 01/31/12, the resident told her roommate and daughter, with a nursing assistant present, she was going to kill herself. The care plan had not been revised to address the resident's continued expressions of [MEDICAL CONDITION]. On 05/21/12 at 1:48 p.m., Employee #2 confirmed there was a problem with the care plans. 2) [MEDICAL CONDITION] medications On 04/03/12, the attending physician ordered [MEDICATION NAME] 20 mg now and then BID (twice a day). During an interview with Employee #2 (director of nursing), on 05/21/12 at 12:45 p.m., she stated, the [MEDICATION NAME] was ordered related to the suicidal ideation. Review of the care plan for Resident #17 found no interventions put in place for staff to follow for the use of [MEDICATION NAME]. According to Employee #2 on 05/21/12 at 1:48 p.m., she was aware the facility had issues with care plans. c) Resident #185 This resident's care plan, dated 05/21/12, identified a problem with alteration in comfort related to chronic back pain. Her care plan identified measures for relieving pain such as position for comfort and to utilize pillows for positioning. During a review of this resident's medical record, there was no evidence she had exhibited back pain since she had been admitted to this facility on 05/09/12. She had exhibited tightness in her chest in the mid-epigastric area on multiple occasions and had been admitted to the hospital on [DATE], when she experienced chest pain. She returned to the facility on [DATE]. The physician had ordered [MEDICATION NAME] 150 mg twice a day, on 05/21/12, [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease). Her care plan had not been revised to reflect chest pain and discomfort after she had experienced this multiple times and been sent to the hospital related to this. . d) Resident #55 Resident #55 received [MEDICAL TREATMENT] treatment three (3) times per week due to end stage [MEDICAL CONDITION]. The care plan review, conducted on 05/21/12, at approximately 9:00 a.m., revealed the facility had care planned the following focus area: Resident exhibits or is at risk for impaired renal function and is at risk for complications related to [MEDICAL TREATMENT]. The goal for this focus area stated: [MEDICAL TREATMENT] access will remain patent x 90 days. The interventions to achieve this goal listed the wrong access site. The resident currently had an arteriovenous (AV) graft to his upper right arm. The care plan addressed an old catheter access site to the right groin. The resident indicated, on 05/21/12, at approximately 9:30 a.m., the [MEDICAL TREATMENT] center used the AV graft in his right upper arm. Further care plan review revealed the facility had not included in the plan, monitoring of the positive bruit and thrill in the AV graft. | 2016-07-01 |