cms_WV: 10418
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10418 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | P.O BOX 70 | BAKER | WV | 26801 | 2011-12-06 | 157 | D | 1 | 0 | H3SV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility failed to notify the resident's legal representative, a family member, and/or the resident's physician when there was a deterioration in the health status of one (1) of six (6) sampled residents until the resident became unresponsive and required hospitalization . Resident identifier: #60. Facility census: 56. Findings include: a) Resident #60 A review of the closed medical record revealed that Resident #60 was an [AGE] year-old female who was admitted to the facility on [DATE], and discharged to an acute care facility on 09/13/11. Her [DIAGNOSES REDACTED]. A review of the nurse's notes revealed the following: -- 08/30/11 at 12:34: Multidisciplinary Care Conference held. The notes state, ". . . met goal for cognition . . . continues to make needs known . . . intake is less than 25% . . . . Patient visits with family, and staff. She watches the birds outside, strolls throughout the building in her wheelchair, eat chocolate and just people watch." -- A second note, at 11:44, stated only that due to a pulse of "47", the resident's [MEDICATION NAME] was held. -- 08/31/11 at 10:56: "(Resident's physician) in to see resident new orders to D/C (discontinue) [MEDICATION NAME] Give Tylenol 650 mg po q 4hrs (by mouth every 4 hours) while awake.". . . "Daughter (health care surrogate's name) notified of new orders." It was also noted the resident's blood pressure medications were held due to pulse rate of "47". -- 09/01/11 at 23:18: It was again noted the resident's blood pressure (BP) medications were held due to low BP of 137/62 and pulse rate of 46. The notes contained no additional nursing assessment or observations. -- 09/02/11 at 14:34: "Physical Evaluation: lethargic, weak. MD (physician) made aware." The entry did note the physician and the responsible party had been notified. It is also noted the resident had been determined to have a significant weight loss (9 pounds in 30 days). -- 09/03/11 at 01:28: A summary note stated: ". . . Due to increased drowsiness, her dose (of [MEDICATION NAME]) was decreased back down from 2mg to 1mg." -- A second note at 19:38 stated: "[MEDICATION NAME] med held due to pt (patient) status. Pt is difficult to arouse, pt assessed and vital signs within normal limits." -- 09/04/11: There were no entries for that date. -- 09/05/11 at 10:40: "Resident lethargic hard to arouse. [MEDICATION NAME] held. VS (vital signs) 121/71-100.4 ax (axillary) -85- 16 . . . Congestive cough." -- 13:20: "Resident remains lethargic not eating or drinking. Opens eyes when name called. Dr. (name) notified . . . Daughter in visiting. Requesting that resident be sent to hospital." -- 14:15: "New order to transfer to (hospital) . . . due to unresponsive, congestive cough, (up arrow) temp. Daughters in room with resident." (notes by Nurse #1). During an interview with a daughter of the resident (not the health care surrogate (HCS)), at 10:30 a.m. on 12/06/11, she stated her younger sister had visited the resident and found her hard to awaken on 09/04/11. Her sister told her the staff said the resident had not eaten for three (3) days. She stated no one from the facility had contacted them about these changes. She also stated when she visited on 09/04/11, Nurse #1 told her they had been attempting to reach the resident's physician for three (3) days without success. During an interview with the daughter who was the HCS for Resident #60, at 10:50 a.m. on 12/0611, she stated she had visited her mother prior to leaving for vacation on 08/31/11. She stated her mother had been awake on that visit and the staff had not voiced any concerns about her health status. She stated she had left the state on vacation the next day. She had no further contact about her mother until her sisters contacted her from the hospital after the resident was transferred there on 09/05/11. She also stated she had examined her telephone for messages and found none. The hospital admission record revealed the resident had arrived there unresponsive with an oxygen saturation level of "61" (normal = 95-100%). Her BUN was "68" (normal = 7.0 - 22.0). Her [DIAGNOSES REDACTED]. During an interview with the director of nursing and the administrator, at 3:30 p.m. on 12/05/11, they were asked to explain why the physician had not been informed earlier of the resident's deteriorating status and why the family had not been notified. They stated they had no information the physician had been unavailable, but would check. They also stated, after reviewing the record, that the responsible party had been notified of weight loss on 09/02/11, per nurse's notes. In a follow-up meeting with the director of nursing and the administrator at 11:45 a.m. on 12/06/11, they acknowledged, after having completed a review of the entire record, that the last contact with the physician prior to the day of transfer, was on 09/02/11. They had no answer when told that none of the daughters had received a call from the facility on 09/02/11, and the HCS had been out of town. The daily entries were reviewed along with the hospital admission record, but they had no additional evidence to indicate additional assessments or attempts to notify the physician and/or family during the week prior to the resident's emergency transfer to acute care. | 2015-04-01 |