cms_WV: 8230
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8230 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 514 | E | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, resident interview, and staff interview, the facility failed to ensure medical records were complete and accurate for six (6) of ten (10) residents reviewed. Resident #49's treatment administration records for pressure ulcers could not be found by the facility. Resident #114's respiratory assessment was completed on 07/01/13 while the resident was not in the facility. In addition, documentation was incorrect regarding the reason an antibiotic was ordered for Resident #114. The allergies [REDACTED]. Residents #116, #123, and #44's medical records did not contain a transfer form. Resident identifiers: #49, #114, #115, #123, #116, and #44. Facility census: 112 Resident findings: a) Resident #49 Resident #49 was admitted to the facility with pressure ulcers. During an interview held with this resident on 07/22/13 at 1:00 p.m., he stated, I had to have surgery on my wounds because they were not changing my dressings. On 0723/13 the treatment administration record was requested for Resident #49. On 07/25/13, Employee #123 (director of nursing) confirmed the treatment administration records for Resident #49 could not be located. On 07/22/13 at 1:00 p.m., Resident #49 alleged the facility did not take care of his wounds and he had to undergo debridement of his wounds. The treatment administration records since admission were requested from the facility on 07/24/13. On 07/25/13 at 8:25 a.m., Employee #123 (director of nursing) with Employee #68 (administrator) present confirmed the treatment administration records from 06/13/13 thru 06/26/13 could not be located. Further review of the medical record for Resident #49 confirmed this resident was sent to the hospital for wound care on 06/26/13. On 07/25/13 at 8:25 a.m., Employee #123 confirmed the facility could not locate the treatment administration records for 06/13/13 thru 06/26/13. b) Resident #114 1) Resident #114 was discharged from the facility on 06/30/13, and sent to the emergency room for evaluation. During a review of the medical record it was discovered Employee #138 (respiratory therapist) completed a respiratory assessment Scale/Pulmonary Index v3 for Resident #114 on 07/01/13. There were several questions to answer about the resident in the performance of this assessment. The following assessment questions were answered by Employee #138: 1. Level of consciousness - alert, oriented, cooperative 2. Activity - non-ambulatory up in chair w/assist 3. Dyspnea Index - SOB w/strenuous exercise 4. Breath Sounds - unilaterally/bilaterally diminished and clear 5. Secretions - moderate, thick 6. Cough - strong/productive 7. Sp 02 - 92-95% 8. Oxygenation - Fi02 less than or equal to 35% 9. Ventilation/Respiration - increased respiratory rate = 20-25 10. Chest X-Ray - unavailable > 7-14 days 11. Respiratory History - past history of smoking and/or his of [MEDICAL CONDITION] disease The respiratory therapist was interviewed on 07/24/13 at 2:00 p.m., with her manager present. During this interview Employee #138 was asked on what date this assessment was completed? She stated, On 07/01/13. She was then asked if this was an accurate assessment of this resident's condition on 07/01/13. She replied, No, because he was not here. She further stated, The information I used to complete this assessment was from a previous assessment on 06/28/13. He was out to the hospital and I could not have seen him that day. She was then asked why she would do an assessment when the resident was not in the facility. She stated, Because I am required to do a respiratory assessment. A copy of the respiratory assessment Scale/Pulmonary Index v3 was given to Employee #138 for review. She was asked if there was any information on this assessment which indicated the assessment information was taken from a previous assessment. She replied, No, it does not say this information was from 06/28/13. She was also asked on 07/24/13 at 2:00 p.m., if this was an accurate assessment of Resident #114 on 07/01/13. She stated, No, it would not be. 2) Review of the medical record on 07/24/13, identified a physician's orders [REDACTED].#90 (licensed practical nurse - LPN) dated 06/29/13. The physician's orders [REDACTED]. Further review of the medical record found a general note written by Employee #90 (LPN), which noted on 06/29/13 at 19:12, the family was notified this resident was ordered [MEDICATION NAME] for a urinary tract infection. During an interview conducted on 07/24/13 at 3:11 p.m., with Employee #137 (family nurse practitioner), she stated she did not order [MEDICATION NAME] for a urinary tract infection. She stated, The [MEDICATION NAME] was ordered for results of a chest-x-ray called to me on 06/29/13, by the facility. Review of the medical record identified a chest x- ray dated 06/29/13, with the following impression: under ventilated lungs, mild cardiomegaly, ill-defined densities left lung base could represent atelectasis or mild consolidation, recommend follow up. Employee #137 stated, I wouldn't have ordered [MEDICATION NAME] for a urinary tract infection. c) Resident #115 Medical records reviewed on 07/23/13 at 8:30 a.m. revealed a Discharge Transition Plan was completed for this resident on 05/29/13. Under the allergies [REDACTED]. Review of the admission assessment and the physician orders [REDACTED].>Interview with Employee #123, the director of nursing (DON) on 07/23/13 at 9:00 a.m., confirmed the Discharge Transition Plan was inaccurate. She further confirmed Resident #115 was allergic to aspirin and sulfa. d) Resident #123 Review of the medical records on 07/24/13 at 2:00 p.m. revealed this resident was originally admitted to the facility on [DATE]. A physician's orders [REDACTED]. No further documentation of the resident's condition at the time of transfer could be located. During an interview on 07/24/13 at 3:00 p.m. with Employee # 123, the director of nursing (DON), she was unable to provide evidence the transfer form was completed by nursing staff and sent to the hospital with the resident. No copy of the transfer form could be located in the resident's medical records. e) Resident #116 Medical record review on 07/23/13 at 11:00 a.m., revealed the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 06/27/13. The resident was re-admitted to the facility on [DATE] and then transferred again on 07/04/13. During an interview on 07/24/13 at 3:00 p.m. with Employee # 123, the director of nursing (DON), she was unable to provide evidence the transfer form was completed by nursing staff and sent to the hospital with the resident. No further documentation could be located in the resident's medical records. f) Resident #44 Medical record review on 07/23/13 at 1:00 p.m., revealed the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 07/18/13. During an interview on 07//24/13 at 3:00 p.m. with Employee # 123, director of nursing (DON), she was unable to provide evidence the transfer form was completed by nursing staff and sent to hospital with the resident. No documentation could be located in the resident's medical records. g) Review of the facility's policy on Discharge and Transfers reads, 5.2. A Patient Transfer Form will be completed and sent to the hospital with the patient. 5.2.1 A copy of the form will be placed in the patient's medical record. | 2016-07-01 |