cms_WV: 8713
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8713 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2013-04-29 | 309 | G | 1 | 0 | LRUF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for eight (8) of fourteen (14) residents reviewed. Resident #98 was admitted with a history of an identified reaction/allergy to [MEDICATION NAME] and [MEDICATION NAME]. The facility flushed the resident's percutaneous intravenous central line (PICC) with [MEDICATION NAME] on three (3) separate occasions. This resulted in harm to Resident #98, as the resident had a reaction and was taken to the emergency room for treatment. Residents #20, #35, #71, and #84 did not have blood pressures taken as ordered. The facility failed to obtain necessary information to ensure pacemaker checks were completed as required for Residents #69 and #83. Wound treatments for Resident #27 were not completed as ordered. Resident identifiers: #98, #20, #35, #71, #84, #69, #83, and #27. Facility census: 95 Findings include: a) Resident #98 This [AGE] year old male was admitted on [DATE] after a recent hospital stay for an acute illness and surgery. During his stay at the acute care facility, he experienced an acute reaction to [MEDICATION NAME] and [MEDICATION NAME] (anticoagulants) . Because of this reaction, the medical records sent with the resident on admission clearly identified the resident's allergy to [MEDICATION NAME] and [MEDICATION NAME]. The records specifically stated, Consult hematology prior to future [MEDICATION NAME] or [MEDICATION NAME] (a low molecular form of [MEDICATION NAME]) and Would avoid all [MEDICATION NAME] products in the immediate future. The resident's admission orders [REDACTED]. The central line catheter protocol form was completed on 03/21/13, and signed at 5:50 p.m., by Employee #22, a registered nurse (RN). Despite the notation in the allergy box, of an allergy to [MEDICATION NAME] and [MEDICATION NAME], the nurse marked the flushing protocol section to . flush unused lumens of the percutaneous intravenous central line (PICC) with 5 milliliters (ml) of normal saline and 5 mls of [MEDICATION NAME]. Review of the medical record, on 04/24/13 at 9:00 a.m., verified the resident received three (3) doses of [MEDICATION NAME] flush through the red port of his central line catheter. The first dose was on 03/20/13 at 9:00 p.m., the second dose was given on 03/21/13 at 09:00 a.m. and the last dose was at 9:00 p.m. on 03/21/13. An order was written to discontinue the [MEDICATION NAME] flush, on 03/23/13 at 4:00 p.m., by Employee #22. A note written by a licensed practical nurse (LPN), Employee #129, stated the resident was transferred out by ambulance, on 03/23/13, for an unplanned evaluation and treatment. Medical record review revealed the resident had been spiking fevers of 99.1 to 104.1., and had two (2) critical lab values: hemoglobin (Hgb) 8.6 (the reference range 12.5 - 16.3) and platelet (plt) count of 63 (reference range 140 - 450) on 03/21/13. Review of the care plan, on 04/24/13, identified the facility had added the notation of the [MEDICATION NAME] allergy to the care plan on 03/26/13, three (3) days after the resident was discharged from the facility. This information was not a part of the care plan when the resident was given [MEDICATION NAME] flushes. During an interview with a registered nurse, Employee #78, on 04/24/13, she acknowledged the care plan was changed on 03/26/13 after the resident was discharged . She stated she had added it because, It had not been care planned. Copies of medical records were obtained from the tertiary care center on 04/24/13 at 9:00 a.m. According to these records, the physicians at the tertiary center were unable to completely rule out a [DIAGNOSES REDACTED]. Due to this, the resident was treated with Argatroban, a direct [MEDICATION NAME] inhibitor. b) Thirteen (13) residents' medical records were reviewed, on 4/23/13 at 9:00 a.m., related to physician's orders [REDACTED]. The orders were not all the same. The review found four (4) of the thirteen (13) residents did not have their blood pressure checks done as ordered. The facility's policy on vital signs, when reviewed on 04/23/13 at 2:55 p.m., revealed vital signs included blood pressure, pulse, respiration, and temperature. The four (4) residents whose blood pressure checks and/or vital signs were not completed as ordered included: 1) Resident #20 A seventy (70) year old woman, was admitted to the facility on [DATE]. She had an active physician's orders [REDACTED]. As of 04/23/13, there was no evidence vital signs (including blood pressure checks) had been taken since 03/04/13. 2) Resident #35 This resident had an active physician's orders [REDACTED]. As of 04/23/13, the only evidence vital signs (including blood pressure checks) were taken were on 03/14/13, 04/17/13, and 04/19/13. 3) Resident #71 This resident had an active physician's orders [REDACTED]. As of 04/23/13, there was no evidence vital signs (including blood pressure checks) had been taken since 02/13/13. 4) Resident #84 A fifty-three (53) year old woman, was admitted to the facility on [DATE]. She had a physician's orders [REDACTED]. As of 04/23/13, the only evidence vital signs (including blood pressure checks) had been taken were on 03/28/13 at 5:05 p.m., 03/28/13 at 10:10 p.m., 03/29/13 at 5:17 a.m., and 03/31/13 at 3:19 a.m. 5) An interview was conducted with the director of nursing, Employee #133, on 04/23/13 at 2:45 p.m. He reviewed the documentation related to blood pressures for Residents #20, #35, #71, and #84, and agreed blood pressures had not been taken as ordered by the physician. c) Two (2) current residents at the facility had pacemakers, Resident #69 and Resident #83. Their medical records were reviewed on 4/23/13 at 10:38 a.m. 1) Resident #69 This resident was admitted to the facility on [DATE]. She had a cardiac pacemaker. There was an active physician's orders [REDACTED]. No cardiologist recommendations or documentation were found in the medical record, and there was no evidence pacemaker checks were done since admission. 2) Resident #83 This resident had a cardiac pacemaker. She had an active physician's orders [REDACTED]. There were notes under the orders that stated last check 3/12/12. There was also a handwritten note that stated, next scheduled pacer check 5/7/13. The care plan stated pacemaker checks were to be done according to cardiologist recommendations; however, no cardiologist recommendations or other details were found in the medical record. 3) The facility policy and procedure for pacemakers was requested. It was reviewed on 04/23/13 at 1:00 p.m. The document, Procedure: Pacemaker Effective Date: 06/01/96 Revision Date: 10/01/12 stated in part: 1.1 Identify type and identification number of pacemaker and document in medical record. 1.2 Review instruction booklet or contact cardiologist for specifics regarding patient's pacemaker. 1.2 Contact pacemaker clinic/physician to schedule regular pacemaker checks. 1.4 Document schedule/instructions for patient's pacemaker checks in patient's care plan and on Treatment Administration Record (TAR) 5. Monitor for function of pacemaker. 5.1 Perform pacemaker checks according to schedule and instructions of pacemaker clinic/physician. 4) The director of nursing, Employee #133, was interviewed on 04/23/13 at 2:45 p.m. He reviewed the documentation and agreed that neither resident's record contained the type, identification number, instructions or specifics regarding the pacemaker. He acknowledged the type of pacemaker determined how often it must be checked. Employee #133 confirmed the facility did not know the type of either resident's pacemaker. He also agreed there was no evidence of pacemaker checks in the Treatment Administration Record (TAR) of either resident. d) Resident #27 This seventy-five (75) year old woman was admitted to the facility on [DATE]. She was admitted for rehabilitation procedures following traumatic fracture of a bone. Her brief interview for mental status (BIMS) score,assessed on 03/13/13 was 15, indicating she was cognitively intact. She was also indicated as interviewable by the facility, on the resident roster they completed. Her medical record was reviewed on 04/24/13 at 8:30 a.m. Resident #27 suffered a fall at home, fracturing her left leg. There were pins in place to secure the fracture. She had a physician's orders [REDACTED].? peroxide and ? normal saline, apply gauze around the pins, and secure them with Kling (gauze bandages that cling to themselves and stretch to conform to body contours) twice each day and more often if needed. The order was written on 02/26/13, and was still active. On 04/24/13, the resident's TARs for March and April 2013 were reviewed: - During March 2013, the treatments were not completed during day shift on March 1, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 23, and 24. The record also showed treatments were not completed during the afternoon shift on March 5, 21, and 25. - During April 2013, the record showed the treatments were not completed during the day shift on April 1, 7, 8, 9, 17, and 22. T he record also showed treatments were not completed during the afternoon shift on April 6, 9, 13, 14, 17, 18, 19, and 21. Resident #27 was interviewed on 04/24/13 at 10:30 a.m. She was asked about her injury and about the treatments that were ordered for her twice each day, and more often as needed. She replied they don't always do it every day. They miss a few days at times. The director of nursing, Employee #133, was interviewed on 04/24/13 at 11:00 a.m. He was shown the physician's orders [REDACTED]. Employee #133 confirmed the evidence indicated Resident #27 did not consistently receive the physician ordered wound care treatments. | 2016-04-01 |