cms_WV: 10094
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10094 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 279 | D | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, and staff interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents to ensure the resident maintained acceptable parameters of fluid and electrolyte balance, by failing to develop and implement a care plan to address fluid and electrolyte balance for a resident with a [DIAGNOSES REDACTED]. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high values of BUN, creatinine, and potassium are also indicative of dehydration.) Further record review revealed the addition of a diuretic, [MEDICATION NAME] 40 mg daily, which was initiated on 12/02/09. No lab results were available for November 2009 or February 2010. Observation of, and interview with, this resident, on 03/02/10 at 8:30 a.m., revealed a pleasantly confused lady who was clean in appearance and well groomed. During this conversation, she threw back the covers and spoke of her TED hose lying at the foot of her bed, saying she would need them on. Both of her legs were [MEDICAL CONDITION], more so on the left, and her finger made an imprint on her left lower thigh when she touched it. On 03/02/10, a medical records person (Employee #12) reviewed the resident's thinned record on file and was unable to find the physician-ordered laboratory tests listed above since 08/31/09. On 03/02/10 at approximately 11:15 a.m., these findings were reported to the director of nursing (DON), who stated she would notify the physician and request an order for [REDACTED]. 2. Medical record review, on 03/03/10, revealed a physician notification form dated 03/02/10 at 11:45, regarding the missing November 2009 and February 2010 labs (BUN, creatinine, and electrolytes). Labs, collected at 12:04 p.m. and reported at 2:12 p.m. on 03/02/10, yielded the following abnormal results: - Potassium - high at 6.1 (normal range 3.5 - 5.2) - Chloride - high at 111 (normal range 97 - 108) - BUN - high at 51 (normal range 5 - 26) - Creatinine - high at 3.53 (normal range 0.57 - 1.00) - eGRF - low at 12 (normal range > 59) Upon notification of these abnormal results, the physician gave orders, on 03/02/10 (with no timed entry for the telephone order), to discontinue the [MEDICATION NAME], give Potassium Chloride 30 meq (additional potassium for an individual who already had an abnormally high serum potassium level), and administer 1000 cc intravenous fluids of D5W (5% [MEDICATION NAME] and water) at a rate of 100 cc per hour with repeat labs in the morning. 3. Record review, on 03/04/10, revealed repeat labs, collected at 7:23 a.m. and reported at 12:13 p.m. on 03/03/10, yielded the following abnormal results: - BUN - high at 49 (normal range 5 - 26) - Creatinine - high at 3.29 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) Review of physician's orders [REDACTED]. Review of nursing notes found an entry, dated 03/03/10 at noon, stating, "2nd (second) blood draw done to confirm K+ (potassium) level before administering [MEDICATION NAME]." A subsequent entry, at 2:00 p.m. on 03/03/10, noted an elevated potassium level of 5.8 with [MEDICATION NAME] given. Another entry, also at 2:00 p.m. on 03/03/10, noted more lab work was scheduled for the morning. 4. Labs, collected at 1:21 a.m. and reported on 03/04/10 (time of report not noted), yielded the following abnormal results: - Potassium - within normal limits at 4.8 (normal range 3.5 - 5.2) - BUN - high at 45 (normal range 5 - 26) - Creatinine - high at 3.42 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) 5. Review of the resident assessment protocol (RAP) summary on the resident's comprehensive admission assessment (dated as completed on 06/06/09) found the interdisciplinary care team decided to not address dehydration / fluid maintenance on this resident's care plan, even though her admitting [DIAGNOSES REDACTED]. Review of the current care plan revealed the problem statement: "At nutritional risk r/t (related to): Therapeutic diet r/t Stg IV CRF (Stage IV [MEDICAL CONDITION])." There was a box to also mark "Dehydration", but the interdisciplinary care team chose not to mark this. The goals associated with this problem statement were: "Resident will consume at least 75% of most meals" and "Weight will remain stable +/- 5 lbs adm (admission weight) 135 lb (also noted +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities)". The interventions to assist the resident in achieving these goals included: "Monitor labs as ordered / available." . | 2015-07-01 |