cms_WV: 8206
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8206 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 309 | D | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure Resident #185 was provided services to attain her highest practicable level of comfort from pain. She did not receive her medication as ordered by the physician to treat her chest discomfort. The resident had a [DIAGNOSES REDACTED]. A medication was ordered by the physician for treatment of [REDACTED]. Additionally, a pain medication given this resident was noted effective on the Medication Administration Record [REDACTED]. Resident identifier: #185. Facility Census: 115 Findings Include: a) Resident #185 During an interview with this resident, on 05/22/12 at 8:15 a.m., she stated her left chest was hurting. She said that they had just given her some medication, but it was still hurting. Her Medication Administration Record [REDACTED]. This was just fifteen (15) minutes prior to the resident expressing she was having pain. It was also recorded, on the MAR, that this medication was effective. This was fifteen (15) minutes after it was administered. In addition, the MAR indicated [REDACTED]. The resident's medical record was reviewed. It was noted this medication had been ordered at 1:40 p.m. on 05/21/12. The medication was scheduled on the MAR indicated [REDACTED] The dose for 05/21/12 at 9:00 p.m. was circled, meaning it was not given. At 8:15 a.m. on 05/22/12, the dose to be given at 9:00 a.m. on 05/22/12 was circled. The nurse (Employee #67) was interviewed on 05/22/12 at 8:45 a.m. She was questioned about the record stating the resident's pain medication was effective. She stated she must have circled that by accident. Employee #67 was then asked why the medication [MEDICATION NAME] 150 mg, that was ordered the day prior to this observation, had been circled as unavailable two (2) times. She stated that it had not yet come in from the pharmacy. The nurse was questioned about the availability of medications in the facility. She stated, They have meds in the Pyxis (an automated machine for dispensing medications), but she would have to go up and check if that is in there. (It was verified that when she referred to the Pyxis, she was actually referring to the facility's in-house medication system which was called the Omni-Cell.) At 8:55 a.m., Employee #67 reported she looked in the facility's Pyxis and the [MEDICATION NAME] was available there so she went ahead and gave the medication. The resident was interviewed again on 05/22/12 at 9:15 a.m. She confirmed that her pain was better after she took her medicine (the [MEDICATION NAME]). This medication had been ordered for eighteen (18) hours and was in the facility to administer, but had not been administered. . II Based on medical record review and staff interview, the facility failed to ensure one (1) of forty-six (46) Stage 2 sampled residents was appropriately monitored for mouth pain in accordance with physician's instructions. Resident identifier: #7. Facility census: 115. Findings include: a) Resident #7 Review of the medical record found a 05/15/12 physician's progress note documenting the resident was examined for complaints of mouth pain. The physical examination documented the examiner found inflammation present, tenderness elicited, Patient with redness and tenderness to tongue, palate, and [MEDICATION NAME] areas. Further review of the progress note found, Assessment: Patient with inflamed (sic) taste buds and oral mucosa. ; decline in status requiring intervention; Plan Add new medication(s); monitor for signs of worsening symptoms; [MEDICATION NAME] swish and swallow QID (four-times-a-day) x 7d (for seven days). Monitor status. Review of the nursing notes found no evidence nursing staff monitored or assessed the resident's oral status in accordance with the instructions and plan of care. This issue was brought to the attention of the director of nursing (DON), Employee #2, on the afternoon of 05/21/12. She was unable to provide evidence of assessment or monitoring of this resident's oral status. | 2016-07-01 |