cms_WV: 10596
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 |
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10596 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 279 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for two (2) of thirty-two (32) residents in Stage II. The antipsychotic medication of Resident #53, with a history prior to admission of exhibiting violent behavior, was discontinued, and the care plan did not direct staff to monitor the resident for a resurgence of violent behavior following discontinuation of the drug, did not identify non-pharmacologic approaches to use when the behavior occurred, and did not specify the therapeutic goal(s) of the other psychoactive medications the resident was still receiving. Resident #219 was admitted for falls and decreased mobility, and care plans for not developed to address either of these concerns. Facility census: 95. Findings include: a) Resident #53 Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 04/02/09 hospital discharge summary revealed the resident had been admitted from another hospital on [DATE], due to violent behavior and increased confusion. "According to the facility administrator, the patient the day prior to admission (on 03/26/09) became very violent and punched 2 female staff members and attempting to twist the wrist of another one, and as a result, was sent to the Emergency Department at __________(on 03/27/09)." Record review resident's admission orders [REDACTED]"agitation", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for "anxiety." A hospital history and physical examination [REDACTED]." A review of the nursing notes found an entry, dated 04/04/09 at 2300, recording, "Wakeful - numerous attempts to get OOB (out of bed) unassisted. Alert - confused x 3." On 04/05/09 the 10:00 a.m., a nurse wrote, "In bed with legs hanging out over the edge - When this nurse attempted to put legs back in bed Resident attempted kick and then striked (sic) at this nurse." A 04/12/09 nursing note recorded the physician's discontinuation of [MEDICATION NAME]. On 05/14/09 the 9:00 a.m., a nurse wrote, "Rsdt (resident) down in bed Nursing Assistants at bedside providing care rsdt. Bent thumb of (nursing assistant) back while turning to change soiled brief." A confidential interview with a nursing assistant who periodically cared for Resident #53, on day shift on 05/21/09, the resident would sometimes try to "stabilize himself ... like reaching out for support, rather than trying to be abusive." On 05/21/09 at 2:00 p.m., the administrator, when interviewed, verified a care plan was developed for the resident and included the use of psychoactive medications, but no plan was developed with respect to monitoring for and responding to violent behaviors after the [MEDICATION NAME] was discontinued. The 04/15/09 care plan for the use of psychoactive medication used terms such as: "He becomes agitated easily and becomes anxious due to the confusion." One (1) intervention was: "Monitor behavior every shift and document." However, it did not describe the type of the behaviors to be monitored (violent physical aggression), did not provide direction to staff regarding how to respond to those behaviors, nor did the care plan provide any therapeutic goals for the resident's use of these psychoactive medication. The stated goal was: "Resident will be free of any discomfort of adverse side effects." b) Resident #219 Review of Resident #219's medical record revealed he was admitted at 6:50 p.m. on 05/18/09, with [DIAGNOSES REDACTED]." The initial care plan, developed to capture the immediate care needs for this resident, did not address falls. The pre-printed initial care plan for "fall / safety risk" was blank, even though this was why he was admitted to the facility. According to the nursing notes, on 05/20/09 at 11:30 p.m., the resident was outside smoking when he fell while getting up from a chair. There was no evidence a falls care plan was initiated after this fall occurred. . | 2015-01-01 |