cms_WV: 11412
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11412 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 328 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents, whose closed record was reviewed, received proper care and treatment for [REDACTED]. Resident #119 was [AGE] years old female who was admitted to the facility from the hospital following a surgical procedure for a [MEDICAL CONDITION]. During a prolonged hospital stay, she was also treated for [REDACTED]. Review of Resident #119's medication administration records (MARs) revealed she was frequently noted to refuse her inhalation treatments; these refusals were not communicated to her attending physician. Facility policy required licensed nursing staff to collect and record physical assessment data regarding the resident's respiratory status before and after the administration of each inhalation, as well as the resident's response to each treatment after it was completed. Review of her nursing notes and MARs found no evidence this physical assessment data was being collected and recorded in accordance with facility policy. The resident subsequently exhibited an acute change in condition, which the certified nurse practitioner ultimately considered was attributable to possible pneumonia. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 for a surgical repair of a [MEDICAL CONDITION], during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - 2. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for [REDACTED].) - 3. Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered." - Review of documentation recorded in the resident's nursing notes and on the September and October MARs found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. - Review of the facility's policy "Aerosolized Medication (Neb Med)" (with a revision date of May 2002) found the following under Item #4 under guidelines: "h. Assess the Resident "(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. "(2) Check respiratory rate prior to treatment." According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: "n. Assess the resident to determine therapeutic outcome. ... "r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken." - During an interview on 11/10/10 at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. - During an interview on 11/10/10 at 4:15 p.m., the licensed practical nurse (LPN - Employee #79), who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering these nebulizer treatments. (See also citation at F281.) - 4. A CNP progress note dated 10/13/10 (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and "the symptom started 7 days ago." Under review of symptoms, the CNP recorded, "The patient complained of malaise and lethargy but denied fever and chills" and she "denied cough". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: "Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication." - A CNP progress note dated 10/14/10 (and electronically signed electronically at 11:59 a.m. the same day) revealed, under chief complaint, "(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation." Under review of symptoms, the CNP recorded, "The patient complained of lethargy but denied fever and chills", "patient denied difficulty swallowing, sore throat and headache", "patient denied sOB (sic) and cough", and "patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was "CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)." The CNP recorded the resident's vital signs as: "blood pressure at Left Arm while Sitting is 135/738 (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed." Under prescriptions, the CNP recorded: "[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on October 14, 2010 and end on October 18, 2010. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on October 14, 2010 and end on October 20, 2010." Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: "Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]." - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on 10/14/10, with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on 10/14/10 (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated 10/14/10 was identified as having been an amendment to the earlier progress note at 1:57 p.m. on 10/14/10. This amendment, which was electronically signed by the CNP at 10:44 a.m. on 10/15/10, contained the exact same information as found on the earlier note for 10/14/10 under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: "Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment." . | 2014-03-01 |