cms_WV: 11105
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11105 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2011-04-27 | 155 | D | 1 | 0 | MWLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and policy review, the facility failed to ensure that a resident's right to refuse treatment. This was evident for one (1) of six (6) sampled residents, who possessed the capacity to understand and make informed health care decisions. The resident refused an injection when he was attempting to leave the facility, and the nurse gave the injection contrary to his wishes. The syringe contained a psychoactive medication ([MEDICATION NAME]). Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 1. Interview with a social worker (Employee #312), on 04/26/11 at 3:30 p.m., revealed that, on 03/03/11, she observed staff physically trying to pull Resident #23, who was attempting to leave the facility. Employee #312 said she went outside and informed staff they could not do that, as the resident has capacity. She stated that, at one point during this incident, a licensed practical nurse (Employee #35) allegedly told the resident, "I have the insulin the doctor wants you to take," but it was [MEDICATION NAME], instead. At that point, the nurse left him alone and did not administer the injection. Employee #312 said, at another point, she looked out her window and saw two (2) maintenance men and the administrator talking to the resident, and the workers had their hands on the resident. She said those staff members somehow got him back inside the fence, and Employee #35 allegedly gave the injection of [MEDICATION NAME] through his clothing. - 2. Interview with another social worker (Employee #119), on 04/27/11 at 8:30 a.m., revealed Resident #23 was determined by his attending physician on 12/10/10 to have health care decision-making capacity, but at the time of the incident on 03/03/11, Resident #23 was extremely out of control. She said this resident walks with a crutch or a cane, and that was his weapon that day, although he did not hit anyone. Both she and the director of nursing (DON) agreed that Employee #35 gave Resident #23 an injection of [MEDICATION NAME] during the incident. - 3. Review of the facility's policy titled "Against Medical Advice Discharge" (revised 09/2008), produced by Employee #119 on 04/27/11 at 12:40 p.m., revealed the following statement: "No capacitated resident will be held in the nursing facility against their wishes, unless with a court order. Any incapacitated resident cannot be responsible for their medical decisions. These residents will not be allowed to leave the facility as they wish." - 4. Interview with Employee #35, on 04/27/11 at 4:30 p.m., revealed when she came to work at 3:00 p.m. on 03/03/11, Resident #23 was already upset and agitated because his wife had come to the facility and brought him some clothing, but he thought he was going home. The family, however, did not want to take him home. Employee #35 asked Resident #23 if she could give him something to calm his nerves, but he refused, so she backed away with the [MEDICATION NAME]. The resident was on the grounds but outside the fence and was in and out of the facility numerous times during this hour-long episode, and police were on the scene at one point. She called the physician, who allegedly told her he had capacity, so let him leave if he wants to, but she spoke her fear that the resident could enter the highway and get killed, and she would be held liable for manslaughter. She said the physician, then, gave her the order to give the resident [MEDICATION NAME] 0.5 mg. According to Employee #35, while staff distracted the resident and tried to take his cane, she gave the injection of [MEDICATION NAME]. Resident #23 was not held down and was not restrained while the injection was given. - 5. Review of the medical record revealed that, on 03/14/11, the facility's medical director (Employee #81) evaluated the resident and determined that he lacked capacity related to dementia with cognitive loss, disorientation to person / place / time, and the inability to understand or make medical decisions, with expected long-term incapacity. - 6. Review of the attending physician's progress notes, dated 03/18/11, found the attending physician "did not have him declared as lacking mental capacity and with some coercion he got [MEDICATION NAME] intramuscularly and apparently he settled down. I have seen him in the clinic since then to see if I need to change his mental status evaluation ... and I did not change it." - 7. During an interview with Resident #23 on 04/27/11 at 4:45 p.m., he said he recalled being mad once when they (facility staff) would not let him leave when he wanted to go home. He did not have clear recall about any injections other than insulin, and he said he had never been hurt by anyone at the facility. . | 2014-08-01 |