cms_WV: 9913
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 |
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9913 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-06-08 | 157 | D | 1 | 0 | D9VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the treating physician was notified when nursing staff members were unable to administer ordered intravenous therapy for fluid replacement purposes. One (1) of six (6) sampled residents was affected. Resident identifier: #202. Facility census: 123. Findings include: a) Resident #202 Review of the medical record found the resident was admitted to the facility on [DATE] for treatment of [REDACTED]. The resident was determined to lack the capacity to make medical decisions by the treating physician on 04/25/12, with adult protective services (APS) appointed as the resident's health care surrogate. On 05/10/12, laboratory results were positive for a [MEDICAL CONDITIONS] infection. The resident was ordered and began receiving [MEDICATION NAME] 500 mg three (3) times a day (tid) on 05/10/12. The nursing notes documented loose, thin, liquid stools on 05/10/12, 05/11/12, 05/12/12, 05/13/ 12, and 05/14/12. treatment for [REDACTED]. On 05/14/12, the resident was visited by the nurse practitioner who documented the resident to be lethargic and hypotensive. The nurse practitioner ordered 2000 cc normal saline intravenous (IV) fluids on 05/14/12. The order, written at 10:20 a.m. on 05/14/12, specified a bolus of 1000 cc of normal saline for the first liter, then 85 cc/hr for the second liter of fluids. Review of the nursing notes found IV access was was obtained at 12:23 p.m. for administration of the first bolus liter of normal saline. Further review of the nursing notes found a note written at 2:07 a.m. 05/15/12, which documented, "Attempted IV access X 2 which was unsuccessful...". The medical record contained no documentation of what circumstances prompted nursing to again attempt IV access. A late entry note, by the nurse practitioner on 05/15/12, documented "nursing reports pulled out IV, received 900 ml of normal saline". The medical record contained no evidence the treating physician was notified the IV site was no longer patent, nor the resident was not receiving the ordered IV fluids. The resident was sent to the emergency room at 1:50 p.m. on 05/15/12 with [MEDICAL CONDITION], altered mental status, and [MEDICAL CONDITION]. An interview with the nurse practitioner, Employee #153, was conducted on 06/07/12 at 1:50 p.m. She stated she did not take calls after leaving the facility and nursing would have to notify the treating physician of the resident's condition and the inability to administer IV fluids. An interview with the director of nursing (DON), Employee #121, on 06/07/12 at 2:00 p.m., verified the resident had pulled out his IV at approximately 9:30 p.m. with no attempts by nursing staff to restart the IV fluids until the unsuccessful attempts at 2:07 a.m. on 05/15/12. She agreed the treating physician should have been notified of the resident's condition and the inability to administer ordered IV fluids. . | 2015-08-01 |