cms_WV: 10359
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10359 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-01-17 | 514 | D | 1 | 0 | CNU711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a record review and staff interview, the facility failed to ensure a resident's medical record was complete and accurately documented. The nursing notes for Resident #22 indicated this resident was complaining of wrist pain. Her left wrist was [MEDICAL CONDITION] and tender to touch. According to the nursing note, the resident "Stated getting arm stuck in SR (side rail) yesterday evening." The nursing notes were not accurately documented to reflect the details of this incident. This resident was not able to speak and she used gestures with her eyes and head nodding to communicate. The resident occasionally mouthed or whispered one (1) word but could not speak in sentences. Also, her ability to move was very limited. This note was inconstant with the resident's physical abilities. The note did not accurately describe how this resident exhibited pain in her hand (i.e. facial grimacing, crying, frowning, flinching, etc.). The nurse who worked the shift, after the resident's hand was observed injured, recorded someone else's information in her nursing notes. This nurse documented what the other nurse told her and not what she had assessed herself. Inaccurate and incomplete documentation in the medical record had the potential to result inadequate treatment. This was true for one (1) of five (5) sampled residents. Resident identifier: #22. Facility Census: 63. Findings include: a) Resident #22 A nursing note, dated 10/04/11 at 04:30 a.m., reflected this resident had pain in her left wrist. Her left wrist was [MEDICAL CONDITION] and tender to touch. According to the nursing note, "The resident stated getting arm stuck in SR (side rail) yesterday evening. Medicated with Tylenol as ordered and per resident request for left wrist pain." This note was not consistent with the resident's condition and abilities to speak, move, or request pain medication. Review of the medical record indicated this resident required total assistance of two (2) people for bed mobility. She was total care for all of her activities of daily living. The resident suffered from an aneurysm, multiple [MEDICAL CONDITION] and [MEDICAL CONDITION]. She also had a feeding tube. The resident's speech was unclear and her ability to communicate was limited to making concrete requests with gestures and an occasional one (1) word vocalization. Another nursing note, dated 10/04/11 at 10:00 a.m., stated, "Resident's L (left) wrist and hand caught in SR (side rail) per resident." Employee #3 was interviewed 01/16/12 at 2:30 p.m. She stated she was the supervisor the day following this incident. Employee #3 said she was the nurse who wrote the note, on 10/04/11, regarding the resident getting her wrist and hand in the side rail. She stated this was what was reported to her in the facility stand up meeting. Employee #3 said she was only recording what the other nurse reported to her. She confirmed she did not actually talk to the resident or investigate the incident. Employee #3 stated she did not recall any investigation of this incident being conducted. She was questioned about this resident's abilities. Employee #3 stated she had never seen this resident move her arm. She verified the resident did not tell her personally she had caught her wrist in the side rail. The director of nursing, Employee #86, was interviewed on 1/17/12 at 10:00 a.m. She verified the nursing notes for Resident #22 did not adequately describe the incident. Employee #86 confirmed the note written by the midnight shift nurse stated the resident said things she was not capable of saying. She stated the nurses probably asked her questions and she nodded her head or used gestures, but that was not evident in the nursing note. She also confirmed Employee #3 should not have documented something as her note when it was actually something another staff member told her. . | 2015-05-01 |