cms_WV: 10598
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10598 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 309 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, family interview, resident interview, and policy review, the facility failed to establish parameters for the administration of pain medication when multiple pains medications were ordered; failed to document the effectiveness of PRN pain medication after it was given; and failed to report to the physician when "as needed" (PRN) medications were used frequently, so the physician would order around-the-clock pain medication for increased pain management. This was evident for three (3) of thirty-two (32) Stage II residents reviewed for pain management. Resident identifiers: #135, #9, and #137. Facility census: 95. Findings include: a) Resident #135 During an interview on the afternoon of 05/19/09, Resident #135 expressed pain in his stomach. Interview with the resident's nursing assistant (Employee #83), at 9:10 a.m. on 05/21/09, revealed Resident #135 did reported stomach pain and received medication for this symptom. Interview with the licensed practical nurse (LPN - Employee #16), at 10:45 a.m. on 05/21/09, revealed the resident expressed stomach discomfort, and this had also been reported by the resident's wife. The wife confirmed this at lunch time when interviewed on 05/21/09. She reported he had an ongoing problem with stomach pain for which they had not been able to determine the cause. He received [MEDICATION NAME], and this brought relief. A review of his medical record revealed Resident #135 had orders for Tylenol 325 mg two (2) tablets by mouth every four (4) hours PRN for pain and [MEDICATION NAME] with [MEDICATION NAME] 10-500 mg tablet by mouth every six (6) hours PRN for pain with a pain assessment to be completed every morning. The pain assessment was to include asking the resident what level the pain he was experiencing prior to medication administration on a scale from "0" to "10", with "10" being the worst. Review of the May 2009 Medication Administration Record [REDACTED]. On the reverse side of the MAR, staff did not always record whether the medication was effective, with such documentation found on only eight (8) or twenty-two (22) days. The notations on the reverse of the form indicated Resident #135 received this medication for back pain on six (6) of the eight (8) dates and for general pain on the other two (2) dates. The presence of back pain had not been identified until these entries were reviewed. There were no parameters to direct staff as to which of these pain medications (Tylenol or [MEDICATION NAME]) was to be administered when the resident reported pain or discomfort, leaving the choice of medication to the discretion of the nurse. During a discussion with the administrator, on the mid-morning of 05/22/09, it was confirmed that the nursing staff failed to obtain clarification orders from the physician to establish the parameters for administering these pain medications. A written policy (with an effective of August 2000) was presented to the surveyors indicated the attending physician must periodically review the resident's use and need for PRN medications, to determine if it needs to be changed or discontinued. No evidence that this occurred was presented by the time of survey exit. b) Resident #9 Review of the May 2009 monthly recapitulation of physician's orders [REDACTED]. The orders did not provide parameters to direct the nursing staff as to when to select one (1) pain medication over specify another for the treatment of [REDACTED]. c) Resident #137 Review of the May 2009 monthly recapitulation of physician's orders [REDACTED]. The orders did not provide parameters to direct the nursing staff as to when to select one (1) pain medication over specify the other for the treatment of [REDACTED]. . | 2015-01-01 |