cms_WV: 9877
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9877 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-07-26 | 514 | D | 1 | 0 | 2QL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, abuse/neglect reportable allegation review, and staff interview, the facility failed to ensure one (1) of nine (9) residents had a medical record that was maintained in accordance with accepted professional standards and practices which includes the records be complete and accurately documented. Resident identifier: #116. Facility census: 114. Findings include: a) Resident #116 On 07/24/12 at 12:00 p.m., the reportable allegations of abuse/neglect review revealed an allegation involving Resident #116. The resident had alleged she did not receive her pain medication ([MEDICATION NAME] 10/325 mg) on the night of 07/08/12. The medical record review revealed the physician had ordered the pain medication every four (4) hours as needed. The facility had contacted the physician and pharmacy on 07/08/12 and a new prescription of the medication arrived on the morning of 07/09/12. The narcotics sign out sheet revealed the facility did have thirty (30) tablets of [MEDICATION NAME] 10/325 mg at 8:00 a.m. on 07/09/12. The resident received a dose at that time On 07/24/12 at 3:00 p.m., the social worker (Employee #18) stated she investigate this allegation of neglect and had found the allegation unsubstantiated. Her investigation included a review of the resident's Medication Administration Record [REDACTED] On 07/24/12 at 4:00 p.m., Employee #65 (registered nurse) stated she came on duty at 11:00 p.m. and at that time Resident #116 had asked about her pain medication. The resident had received a dose of [MEDICATION NAME] 10/325 mg at 8:00 p.m. Employee #65 said she explained to the resident the situation involving the need to get a new prescription of [MEDICATION NAME]. She told the resident the pharmacy would deliver the new prescription on the morning of 07/09/12. Employee #65 said she informed the resident she could contact the physician and ask for an alternate pain medication. The resident declined. According to the nurse, the resident had previously stated [MEDICATION NAME] did not help her and she did not want to take [MEDICATION NAME]. According to the nurse, the resident went to bed and rested throughout the night. On 07/09/12, the resident alleged she had not received her pain medication as ordered. The medical record review revealed Employee #65 had not documented the above events in the resident's clinical record. She was able to remember the situation and recount what happened on 07/08/12, however, she had not documented this information. According to American Health Information Management Association guidelines for charting in long term care medical records: "A complete record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care and provides sufficient documentation of the effects of the care provided. Documentation should provide a picture of the resident, including what resident said or did, observations and/or assessments by staff, communications with practitioners and legal representative, response to interventions/treatment. Good practice indicates that for functional and behavioral objectives the clinical record should document change toward achieving care plan goals." . | 2015-08-01 |