cms_WV: 11413
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11413 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 514 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to maintain, in accordance with accepted standards of professional practice, the medical record of one (1) of six (6) sampled residents whose closed record was reviewed. Review of the closed record for Resident #119 revealed licensed nursing staff failed to document every change in her condition until her condition was stabilized or the situation was otherwise resolved, in accordance with professional standards of practice. Late entries in Resident #119's nursing notes were not recorded as soon as possible, with one (1) nursing note containing six (6) separate late entries having been recorded seven (7) days after the resident expired, even though the author of that note was working in the facility two (2) days after the resident transferred to the hospital. Additionally, a review of hospital discharge orders from the physician prior to Resident #119's admission on [DATE] found an order for [REDACTED]. The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This discrepancy in frequency of administration of the inhalation treatments was not identified previously by the facility. These practices did not allow for accurate and complete clinical information about this resident's change in condition and treatments. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed record revealed this [AGE] year old female was admitted to the facility on [DATE] after a prolonged hospital stay. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, "Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach." The next consecutive entry, dated [DATE] at 5:10 p.m., stated, "N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware." Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, "Resident vomited x 3 this shift. Will monitor." This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, "Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee." This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, "N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention." This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, "N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, "QMI (name of mobile imaging company) on site; CXR (chest x-ray) done." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, "MPOA notified of decline; wish (sic) to send to TMH (area hospital)." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, "KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants." The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, "Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]." - According to the AHIMA LTC documentation guidelines: "5.2.15. Condition Changes "Every change in a resident's condition or significant resident care issues must be noted and charted until the resident's condition is stabilized or the situation is otherwise resolved. Documentation that provides evidence of follow-through is critical." The licensed nursing staff failed to note and chart every change condition or significant resident care issues involving Resident #119's health status in accordance with professional standards of practice. -- 2. Review of the closed medical record for Resident #119, who was transferred to the hospital on the evening of [DATE] and subsequently expired, found a nursing note, dated [DATE] at 3:27 p.m., which contained six (6) separate late entries describing events said to have occurred one (1) week earlier between 1:00 p.m. and 5:00 p.m. on [DATE]. - According to the "as-worked" nursing schedule provided at 3:30 p.m. on [DATE] by the director of nursing (DON - Employee #81), the author of the late entries recorded on [DATE] (a licensed practical nurse (LPN - Employee #19)) worked from 7:00 a.m. to 7:30 p.m. on [DATE]. During the 7:00 a.m. to 7:30 p.m. shift on [DATE], Employee #19 recorded entries at 4:-0 (exact time not legible), 5:25 p.m., 7:00 p.m., and 7:22 p.m.; Employee #19 worked in the facility again from 7:00 a.m. to 7:30 p.m. on [DATE], and from 7:00 a.m. to 7:30 p.m. on [DATE] and would have been available to record these late entries more timely than she did. - According to the AHIMA LTC documentation guidelines: "5.3.2.1. Making a Late Entry - When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record. ... "When using late entries document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes." The late entries recorded by Employee #19 were not entered into Resident #119's record as soon as possible (which would have been during the 7:00 a.m. to 7:30 p.m. shift on [DATE]. Instead, they were recorded seven (7) days after the resident expired. This significant delay in recording the late entries calls into question the reliability of their contents. -- 3. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on [DATE] following a prolonged hospital stay beginning on [DATE] during which she received treatment for acute [MEDICAL CONDITION] (ARF). Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. - Review of the [DATE] MAR found, for her only day present in the facility in September ([DATE]), she had an order to receive [MEDICATION NAME] inhalation treatments every six (6) hours (at regular intervals four (4) times a day). Review of the [DATE] MAR indicated [REDACTED]. - In an interview at 3:30 p.m. on [DATE], the DON reported the resident was to have received the inhalation treatments every four (4) hours and the physician orders [REDACTED]. - Review of a progress note dictated by the certified nurse practitioner (CNP), dated [DATE] and electronically signed at 2:39 p.m., found an entry stating to continue to nebulizer treatment for two (2) weeks and re-evaluate. Review of the physician orders [REDACTED]." Further review of physician orders [REDACTED]. Based on the information available in the resident's closed record, it is unclear when one (1) or more transcription errors may have occurred - when the CNP recorded the handwritten order to continue the [MEDICATION NAME] treatments on [DATE] (at a frequency different from what was specified in the resident's hospital discharge order), or when the order was carried over from the [DATE] MAR indicated [REDACTED] | 2014-03-01 |