cms_WV: 9946
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9946 | WELLSBURG CENTER LLC | 515123 | 70 VALLEY HAVEN DR | WELLSBURG | WV | 26070 | 2010-07-08 | 329 | D | 0 | 1 | GJYW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the medical record and staff interview, the facility failed to ensure the medication regimens of three (3) residents of twenty-three (23) Stage II sample residents were free of unnecessary drugs, used in excessive dose, without adequate monitoring, without adequate indications for use, and/or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Resident identifiers: #58, #8, and #28. Facility census: 49. Findings include: a) Resident #58 Review of Resident #58's medical record revealed this [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her physician's orders [REDACTED]. 12/10/09). Review of the resident's comprehensive admission assessment, with an ARD of 12/15/09 again found the assessor noted the resident did not exhibit any indicators of depression, anxiety, and/or sad mood in the preceding thirty (30) day period. The assessor did note the resident exhibited the following behavioral symptoms during the preceding seven (7) day period: wandering (daily), verbally abusive (1-3 days), physically abusive (1-3), and resists care (1-3 days). Further record review revealed her most recent assessment was a comprehensive significant change in status assessment with an assessment reference (ARD) 03/30/10. In Section E of this assessment addressing mood and behavior patterns, the assessor noted the resident did not exhibit any indicators of depression, anxiety, and/or sad mood in the preceding thirty (30) day period and did not exhibit any behavioral symptoms in the preceding seven (7) day period. The assessor also noted the resident's behavioral symptoms had improved over the preceding ninety (90) day period. An interview with the assessment coordinator (Employee #20), on 07/01/10 at 11:00 a.m., revealed the resident had been very ill and her behaviors had decreased, but now they had increased. A review of the resident's care plan revealed, "Behavior problems wandering daily makes her at risks for falls. Physical and verbal abuse less than daily related to dementia has shown an improvement due to a decline in her health." - A pharmacy note, dated 03/23/10, stated, "This patient is receiving [MEDICATION NAME] ([MEDICATION NAME]) 1 mg three times a day for anxiety. The recommended geriatric dose is 2 mg per day. Please consider a gradual dose reduction to the recommended geriatric dose." On 04/01/10, the physician ordered: "Discontinue all previous [MEDICATION NAME]. Begin [MEDICATION NAME] 0.5 mg twice a day at 9 AM and 5 PM due to anxiety state. [MEDICATION NAME] 1 mg at 9 PM." A facility form "Physicians Communication Form", dated 04/08/10, contained a recommendation from the pharmacist to the physician to decrease the total daily dosage of [MEDICATION NAME] from 3 mg to 2.5 mg and to continue with the gradual dose reduction to 2 mg, noting that the maximum daily dose of [MEDICATION NAME] recommended for the elderly was 2 mg daily. The physician's response was: "See progress note." A physician's progress note, dated 04/13/10, stated, "Continue [MEDICATION NAME] as some increase in aggression noted recently." Nursing notes from 04/02/10 to 04/21/10 reflected no behavior problems exhibited by the resident. - On 04/21/10 at 3:45 a.m., a nursing note indicated, "Resident has been awake all night, chooses not to go to bed. Up out of wheelchair without assistance multiple times. 1:1 (one-on-one intervention) effective for short intervals." At 4:50 a.m. on 04/21/10, a nursing note indicated, "In front of nursing station, stood and fell hitting head on left side. Neuro checks recorded, denies pain. No injuries from previous fall, slept all night." On 04/25/10 at 3:00 p.m., a nursing note revealed, "Resident sitting in wheelchair at nurse's station (sic) alarm to chair went off. Observed resident stand and then sit on floor. No injuries." On 04/26/10 at 3:10 a.m., a nursing note indicated, "Resident awake until 2:45 a.m. (sic) was highly agitated for a short time, yelling and cursing at staff very loudly. Was about to administer PRN (as needed) [MEDICATION NAME] when resident calmed down and fell asleep in her wheelchair. Resident awakened and began to yell again. The resident became calmer after a short time. " On 04/28/10 at 3:30 a.m., a nursing note stated, "Resident sitting in wheelchair at nurse's station refusing to go to bed (sic) delusions that she needs to go home. 1:1 ineffective." At 1:30 p.m. on 04/28/10, a nursing note stated, "Discussed with physician verbal aggression continues today, unable to get along with other residents. Increased ambulation in hallways independently, yelling at others for no apparent reason. Physician order [REDACTED]." On 04/28/10, the physician increased the [MEDICATION NAME] to 1 mg three (3) times a day, for a total daily dose of 3 mg. - An interview with the clinical care coordinator, on 07/06/10 at 10:05 a.m., revealed the resident's behaviors were better today. The resident was able to ambulate but leaned forward and her gait was unsteady. She was very tired a lot and needed to be reminded to use her walker. "If you remind her to use the walker, she will get agitated easily." An interview with a nurse (Employee #53), on 07/06/10 at 10:15 a.m., revealed [MEDICATION NAME] is used when the resident becomes agitated, and this is the only thing that will calm her down. Employee #53 also noted, due to the amount of psychoactive medication she was taking, the resident was a falls risk and she had had falls in the past. In addition to the routine doses of [MEDICATION NAME] and [MEDICATION NAME], a review of the resident's medication administration records (MARs) found she received [MEDICATION NAME] 2 mg IM injections on 02/01/10, 02/02/10, 02/03/10, 05/01/10, 05/02/10, and 06/26/10. A review of the facility's accident / incident reports for April, May, and June 2010 revealed that the resident had seven (7) falls during this time period. The resident did not sustain injuries. - An interview with the staff development nurse (Employee #57), on 07/06/10 at 10:45 a.m., revealed the behavior management system was broken. Staff was not documenting what the resident was actually doing in the medical record. She further stated the physician had done a lot that also was not documented. She stated she documented interventions in the nursing notes and not in the care plan. At 10:48 a.m., the director of nursing (DON) came into the interview and agreed with Employee #57. - An interview with the pharmacy consultant, on 07/06/10 at 1:30 p.m., revealed the [MEDICATION NAME] 2 mg PRN injection was not suitable unless the resident was a hospice patient. The pharmacy consultant stated he should have written a recommendation to address the use of [MEDICATION NAME] PRN. He further stated this was a drug that you would not want the nurse using their discretion to administer. - An interview with the DON, on 07/08/10 at 10:00 a.m., revealed the resident had certain staff that could work with her, and, depending on the approach used by staff, the resident would not exhibit the aggressive behaviors. A review of the care plan did not find any interventions regarding how to approach the resident so as not to trigger the aggressive behaviors, as mentioned by the DON during the interview at 10:00 a.m. on 07/08/10. -- b) Resident #8 Medical record review, on 06/30/10, revealed Resident #8, a [AGE] year old female admitted to the facility on [DATE], exhibited behaviors including tearfulness, verbal abuse, and repetitive health complaints, and the physician ordered the antipsychotic medication [MEDICATION NAME] 25 mg by mouth daily for [MEDICAL CONDITION]. Review of the resident's behavioral monitoring tracking record found the behavioral symptoms occurred infrequently, with only two (2) episodes in the months of April and May 2010. On 05/16/10, she was verbally abusive, and on 04/26/10, she was physically abusive; documentation indicated, in both instances, the behaviors were easily altered with 1:1 interventions. When interviewed on 07/01/10 at 9:23 a.m., a nurse (Employee #62) related that it was unusual for Resident #8 to have behaviors, and she had not personally witnessed the resident exhibiting any of these behaviors. When interviewed on 07/01/10 at 9:35 a.m., another nurse (Employee #48) reported Resident #8's behaviors occurred infrequently; the last time she exhibited any behaviors was on 06/24/10 and, prior to that, it was in May. Employee #48 also identified that, when the resident exhibited behaviors in June, she was successfully redirected with 1:1 staff interaction. Review of the resident's care plan found no plan had been developed to ensure non-pharmacologic interventions (such as 1:1 staff intervention) were attempted in an effort to decrease the episodes of behaviors. -- c) Resident #28 Medical record review, on 07/06/10, disclosed Resident #28, an [AGE] year old male, was admitted to the facility on [DATE]. He was hosptalized on [DATE] and returned to the facility on [DATE]. According to his nursing notes, in the early morning hours of 04/12/10, Resident #28 began experiencing increased anxiety. At 1:30 a.m., staff contacted the physician, who ordered an antianxiety medication ([MEDICATION NAME] 0.5 mg one (1) time only due to anxiety) and a respiratory treatment ([MEDICATION NAME] unit dose one (1) time dose due to [MEDICAL CONDITION]). On 04/20/10 around 3:00 a.m., Resident #28 again began to have increased anxiety. Staff contacted the physician, who again ordered [MEDICATION NAME] 0.5 mg by mouth now one (1) time dose due to increased anxiety and [MEDICATION NAME] unit dose one (1) time dose due to increased shortness of breath. On 04/20/10 at 5:30 p.m., the physician ordered an antidepressant, [MEDICATION NAME] 25 mg every day for seven (7) days then increase to 50 mg every day. On this same date at 8:20 p.m., the physician also ordered [MEDICATION NAME] 0.5 mg three (3) times a day as needed for anxiety. When interviewed on 07/01/10 at 9:40 a.m., Employee #48 reported Resident #28 behaviors were mainly triggered when he was due for a bath or to be turned. Review of the resident's current care plan, dated 05/20/10, found the addition of both the antianxiety and antidepressant medications, but only in the context of the need to monitor for potential adverse drug-related complications associated with these medications. The care plan did not address what behaviors the resident exhibited that indicated he was experiencing increased anxiety. There was no discussion of causative factors in the environment that may have triggered this increased anxiety (such as how staff approached him for bathing and turning), nor was there any mention of non-pharmacologic interventions to be attempted prior to medicating the resident with the as needed [MEDICATION NAME]. Additionally, there was no discussion of what causal or contributing factors were identified with respect to the resident's signs / symptoms of depression. -- d) When interviewed on 07/06/10 at 10:44 a.m., the staff development coordinator (Employee #57) revealed the care plans only had information concerning the side effects of the psychoactive medication being used; they did not address any non-pharmacologic interventions for modifying behaviors. Employee #57 stated, "Our behavioral management system is broken, and we do a lot of talking that is not captured .... The behavior management care plan is something that we need to work on." . | 2015-08-01 |