cms_WV: 10816
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10816 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2011-08-17 | 309 | E | 1 | 0 | YCK011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure each resident received medications as ordered by the physician, failed to promptly notify the physician when a resident frequently refused one (1) or more medications, failed to notify the responsible party when the resident did not received scheduled doses of medications for an extended period of time, and failed to establish a care plan to address either the resident's refusal of medications or to address the need to monitor those health conditions for which the medications were not have been administered (but were not). This affected ten (10) of (10) sampled residents. Resident identifiers: #4, #8, #41, #44, #57, #62, #75, #78, #79, and #80. Facility census: 77. Findings include: a) Resident #78 1. Review of the resident's medication administration records (MARs) from October 2010 found the resident had a history of [REDACTED]. - [MEDICATION NAME] 100 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 13 doses and missed 1 additional dose (reason unspecified); med discontinued on 10/14/10 - [MEDICATION NAME] 2 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 15 doses and missed 4 additional doses (reason unspecified); order changed on 10/16/10 - [MEDICATION NAME] 10 mg 1 tablet by mouth twice daily for dementia with behavior disturbances - refused 12 of 62 doses and missed 6 additional doses (reason unspecified) - [MEDICATION NAME] 2 mg 1 tablet by mouth for hypertension - refused 3 of 31 doses - [MEDICATION NAME] XL 300 mg 1 tablet by mouth for [MEDICAL CONDITION] - refused 1 of 14 doses; med discontinued on 10/14/10 - [MEDICATION NAME] sodium 200 mg 1 by mouth at bedtime for constipation - refused 12 of 31 doses and missed 3 additional doses (reason unspecified) - [MEDICATION NAME] 25/200 1 tablet by mouth twice daily for hypertension - refused 14 of 62 doses and missed 5 additional doses (reason either unspecified or unclear) - [MEDICATION NAME] 17 grams in 8 oz water by mouth for constipation - refused 3 of 31 doses - [MEDICATION NAME] OTC 20 mg 1 tablet by mouth for [MEDICAL CONDITION] reflux - refused 3 of 31 doses - [MEDICATION NAME] liquid 400 mg by mouth twice daily as an appetite stimulant - refused 20 of 62 doses, missed 8 additional doses (reason either unspecified or unclear), and no initials were present to indicate whether 1 doses was administered or not - [MEDICATION NAME] 10 mg by mouth at bedtime for dementia with behavior disturbances - refused 11 of 31 doses and missed 5 additional doses (reason not specified) - [MEDICATION NAME] 10/100 1 tablet by mouth three-times-daily for [MEDICAL CONDITION] - refused 43 of 93 doses and missed 5 additional doses (reason either unspecified or unclear) - [MEDICATION NAME] 7.5 mg 1 tablet by mouth for [MEDICAL CONDITION] - refused 1 of 14 doses; med discontinued on 10/14/10 On the reverse side of the MAR for the medications ordered for administration on an "as needed" (PRN) basis, nurses recorded that medications offered at 9:00 p.m. on the following dates were not administered because the resident would not awaken to take them - 10/01/10 through 10/06/10, 10/11/10, 10/12/10, 10/15/10, 10/16/10, and 10/22/10. Further review of MARs, from November 2010 through January 2011, found documentation reflecting multiple doses of medications were not being administered as ordered by the physician. Coding on the MARs indicated the resident would frequently refuse to take his scheduled doses of medications; however, he had multiple additional missed doses, the reasons for which were either unspecified or not clearly stated. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered - for whatever reason. - 2. On 02/10/11, the following medications were discontinued: [MEDICATION NAME] sodium, [MEDICATION NAME], [MEDICATION NAME], [MEDICATION NAME] 7.5 mg twice daily (which was started on 12/29/10), and [MEDICATION NAME]. (Previously, [MEDICATION NAME] had been discontinued on 01/07/11.) On 02/21/11, the physician ordered [MEDICATION NAME] 2 mg by mouth twice daily for tremors. Review of the MARs from February to April 2011 revealed multiple missed doses for which staff failed to record the reason for not administering them, and the [MEDICATION NAME] was discontinued on 04/14/11. - 3. On 04/14/11, the physician ordered the following medications: [REDACTED] - [MEDICATION NAME] 10/100 1 tablet by mouth three-times daily for [MEDICAL CONDITION] - [MEDICATION NAME] 200 mg by mouth for arthritis - Klonopin 0.5 mg 1 tablet by mouth three-times-daily for agitation (which was subsequently changed to 0.25 mg twice daily on 04/28/11, and back to 0.5 mg three-times-daily on 06/17/11) On 06/14/11, the physician ordered [MEDICATION NAME] SR 150 mg by mouth daily for depression. Review of the MARs for April, May, and June 2011 found virtually all scheduled doses of these medications were not administered. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered over this 2-1/2 month period. - 4. Review of Resident #78's care plan, last revised on 07/05/11, revealed the following intervention (created on 07/02/11) to address problems associated with unrelieved pain: "Resident to be given all medications with MPOA (medical power of attorney) and second nurse present per MPOA request." There was no evidence of any plan having been implemented prior to 07/05/11 to address the need to monitor the resident's overall health status related to various health conditions (e.g., hypertension, constipation, [MEDICAL CONDITION], etc.) that would have been affected by frequent missed doses of scheduled medications and/or by the discontinuation of medications to treat these conditions. - 5. Review of the facility's self-reported allegations of abuse / neglect found an report of an allegation of neglect made by Resident #78's spouse, dated 07/05/11, stating (quoted as written), "Resident Responsible party reported to this social worker on this date alligations of neglect stating nursing failed to give medications per order and neglected to notify responsible party & physician when documented refusal to take medications. Investigation being conducted." - 6. During an interview with the administrator and the director of nursing (DON) on 08/16/11 at 11:30 a.m., the DON presented policies about medication administration, but the policies did not address what actions staff was to take when a resident repeatedly refused medications - beyond the action of documenting the refusal by circling the nurse's "initials in the date and time space where that medication is ordered, and document(ing) patient's refusal of medication on the back of the MAR". (Policy titled "8.4 Medication Administration: General" revised 05/01/11.) The DON stated they implemented a new practice whereby, if a resident misses 3 doses of any medication, the physician is to be notified as well as the resident's responsible party. They verified Resident #78 did not receive his medications as ordered over an extended period of time and that neither the physician nor the resident's responsible party had been notified when this occurred. - 7. Residents #4, #8, #41, #44,57, #62, #75, #79, and #80 Further review of the facility's self-reported allegations of abuse / neglect found the facility identified, upon investigating concerns about medication administration with Resident #78, nine (9) other residents who did not receive their medications as ordered. An interview with the administrator and DON, on 08/16/11 at 11:30 a.m., found they identified a total of ten (10) residents (including Resident #78) who frequently did not to receive their medications as ordered. They said they implemented a plan to address this, which included notification of the resident's physician and notification of the resident's responsible party (in the event the resident had a surrogate decision-maker acting on his or her behalf due to a determination of incapacity). . | 2014-12-01 |