cms_WV: 10971
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10971 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2011-06-02 | 157 | D | 1 | 0 | 9FE011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, facility record review, and staff interview, the facility failed to notify the family member / legal representative of one (1) of five (5) sampled residents (who recently passed away), when a significant change in a resident's physical condition occurred and a new and/or altered treatment was ordered by the physician. Resident identifier: #102. Facility census: 100. Findings include: a) Resident #102 Review of Resident #102's closed record found a nursing note, dated [DATE] at 6:50 p.m., stating Resident #102 developed a fever of 101.3 degrees Fahrenheit, his oxygen saturation level was low at ,[DATE]%, and his lung sounds were diminished. The physician was notified by the registered nurse (RN - Employee #54), but there was no evidence the resident's medical power of attorney representative (MPOA) had been notified. In a telephone interview with Employee #54 on [DATE] at 11:30 a.m., the RN revealed that Resident #102 experienced a change of condition on [DATE] at 6:50 p.m., whereby he developed a fever and his lungs sounded congested. She said she notified the physician via fax at 6:50 p.m., and then got busy while awaiting the physician's response. Then it got late, so she did not call the MPOA. Her shift ended at 10:00 p.m., and she gave a report of his condition change to the night shift RN (Employee #69). The physician faxed orders to the facility at 10:30 p.m., after her shift had ended. Review of a physician order [REDACTED]. In an interview on [DATE] at 2:30 p.m., Employee #69 confirmed she was on duty at 10:30 p.m. on [DATE] when the physician's orders [REDACTED]. When asked if she called the MPOA of the new order for the chest x-ray to be done the following morning, she stated that she normally does not call people late at night unless something really bad is going on, and she did not want to alarm the family, so she did not call the MPOA about the new order. She said she was completely shocked that Resident #102 passed away on [DATE]; his death was not expected. Review of Nurse's Notes dated [DATE] at 1:35 p.m. revealed Licensed Practical Nurse (LPN) #53 assessed Resident #102 as having a low oxygen saturation level of 82- 84% on room air and 93% on 2 (two) liters of oxygen; unable to eat; not responding; lethargic; temperature 100 degrees; no signs or symptoms of shortness of breath or distress noted. During an interview on [DATE] at 2:15 p.m., a licensed practical nurse (LPN - Employee #53) recalled having told an RN on [DATE] that Resident #102 was not doing well, but she did not recall which RN she told. She described Resident #102 on [DATE] as being pale, using oxygen, having no intravenous fluids. She said, in the morning, he had a chest x-ray and he seemed fine, although he was sleeping a lot and had a fever; he had no shortness of breath even when his his oxygen saturation level was at 82% on room air. She said the oxygen concentrator was already in his room, so she began oxygen at 2 liters per minute per nasal canula. She explained that his oxygen level would drop sometimes even when he was not sick. She said staff just happened to check the oxygen saturation level that day, but for no particular reason that she recalled. Review of a physician's orders [REDACTED].#111), revealed a new order for an antibiotic, [MEDICATION NAME] nebulizer treatments three (3) times daily for five (5) days, to check his temperature every shift for the next twenty-four (24) hours then daily while on the antibiotic, and recheck the chest x-ray in three (3) weeks. In an interview on [DATE] at 10:10 a.m., Employee #111 revealed she was the day shift supervisor on [DATE]. She said she did not recall Employee #53 telling her that Resident #102 was fevered or had lowered oxygen saturation levels. She stated she received the chest x-ray results that morning and immediately faxed the report to the physician. She acknowledged that she received orders from the physician at 1:45 p.m. on [DATE] for antibiotic therapy, [MEDICATION NAME] nebulizer treatments, temperature monitoring, and to repeat the chest x-ray in three (3) weeks. She said she passed that information along to the oncoming RN supervisor (Employee #54), as her own shift ended at 2:00 p.m. She said she did not recall telling Employee #54 anything about family notification, but she recalled that Employee #54 told her she would go in and check Resident #102. She said she was shocked to learn the following day that Resident #102 had expired on [DATE], noting his death was unexpected. In an interview on [DATE] at 11:30 a.m., Employee #54 stated she reported to work at 2:00 p.m. on [DATE]. She stated Employee #111 had received orders from the physician at 1:45 p.m. (around the change of shift) on [DATE]. She did not recall whether Employee #111 left out the 1:45 p.m. physician order [REDACTED]. She said when she called the family at 4:30 p.m. on [DATE] to report that Resident #102 had expired, it was then that she realized the family had not been notified of his condition change. She said, normally, nurses notify the family of condition changes, new orders, and changes in treatments, but this was not the case this time due to miscommunication among staff. Review of a grievance / complaint report dated and signed on [DATE], and produced by the director of nursing (DON) on [DATE] at 3:10 p.m., acknowledged that Resident #102's MPOA reported she was not notified in a timely manner of a significant change in condition with Resident #102, and she felt she could have spent the last moments with him had she been notified her in a timely manner at 6:50 p.m. on [DATE]. Attached to the complaint was an Employee Education Document noting this form was being completed to offer support of education provided to Employee #111. A description of the education being provided to this employee regarded notification of family / MPOA when there is a significant change with a resident; it noted the physician was notified in this case, but the MPOA was not notified. During an interview on [DATE] at 10:00 a.m., the DON said she was unable to find a policy related to family notifications of significant changes, but she found a "Bill of Rights" in-service handout that the licensed social worker (LSW) presents annually, and most recently presented to nursing staff on [DATE]. She said, in part, this handout states the facility shall immediately inform the resident and consult with the resident's legal representative of a significant change in the resident's physical, mental, or psychosocial status. Also, she produced a copy of the RN supervisor's job description. On page 2, the duties were found to include: "Contact POA (Power of Attorney) or appropriate family member when there is a change in Resident's condition." When interviewed on [DATE] at 12:40 p.m., the LSW (Employee #52) revealed that significant change care plan meetings are held if a resident is terminal or declining, and the option of hospice is discussed. She stated if there is a decline in a resident, the family should be notified. She said she thought that Resident #102's MPOA should have been notified of a change in condition when it occurred that weekend in April. She looked at the inservice handout on "Bill of Rights" and acknowledged that she gave that inservice on [DATE], and that it was given every year for nursing staff. . | 2014-10-01 |