cms_WV: 9923
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
9923 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-10-05 | 514 | D | 0 | 1 | TTVD12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure an accurate medical record for two (2) of twenty (20) residents in the sample. The monthly recapitulation orders did not contain revisions and changes made from one month to the next. Resident identifiers: #53 and# 42. Facility census 49. Findings include: a) Resident #53 A review of the medical record revealed the physician's orders [REDACTED]. During an interview with the director of nurses (DON), at 8:50 a.m. on 10/4/12, she stated the resident no longer had pressure ulcers. She said they were healed in August and treatment was discontinued. She located evidence of this in the record. Upon review of the record, she agreed the orders for treatment had not been deleted from the record. . b) Resident #42 Review of the resident's medical record, at 10:00 a.m. on 10/03/12, revealed the October 2012 recapitulation orders contained five (5) orders that had been discontinued. The orders on the recapitulation were indicated accurate by the director of nursing services (DON), Employee #20, on 09/28/12. Additionally, the physician approved the orders, by signature, on 10/01/12. An order was present for monitoring an incision site on the resident's back for signs and symptoms of infection due to status [REDACTED]. Review of the treatment administration record (TAR) revealed this treatment was discontinued on 09/28/12. Interview with the treatment nurse (Employee #48) at 10:15 a.m. on 10//03/12 confirmed this area was healed on the date indicated on the TAR. There was an order for [REDACTED].#20, on 10/04/12 at 12:00 p.m., she clarified the resident went to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The resident's physician's orders [REDACTED]. According to the TAR, the stage II pressure ulcer was healed on 08/23/12. During the interview with Employee #48, at 10:15 a.m. on 10/03/12, she confirmed the pressure ulcer was healed on the date indicated on the TAR. An order was present for the application of [MEDICATION NAME] twice daily to the resident's right [MEDICAL CONDITION] stump. According to the TAR, this treatment was discontinued on 09/19/12. Interview with the treatment nurse, Employee #48, at 10:15 a.m. on 10/03/12, confirmed this treatment was discontinued on the date indicated on the TAR. The medical record contained a physician's orders [REDACTED]. Observation on 10/04/12 at 3:00 p.m., with Employee #48, revealed the mattress on the resident's bed was not an air mattress, but was instead a pressure relieving mattress. Employee #48 stated there would be a pump mechanism at the foot of the bed were this an actual air mattress. . | 2015-08-01 |