cms_WV: 11426
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11426 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-09-01 | 309 | G | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to treat the resident's anxiety. Resident #152 was admitted to the facility on [DATE] following a hospitalization for urinary tract infection [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Nursing staff at the facility failed to appropriately assess and monitor this resident for exacerbation of these conditions. Nursing staff failed to institute neurological assessments for Resident #152 (who was receiving [MEDICATION NAME] therapy which placed her at high risk for bleeding) following a fall sustained on 12/05/10. Nursing staff members did not begin monitoring the resident's neurological status until the evening of 12/07/10, and the director of nursing (DON), when interviewed, stated these neuro-checks should have been initiated immediately after the fall. Additionally, Resident #152, who had a [DIAGNOSES REDACTED]. These practices had the potential to result in more than minimal harm to an isolated number of residents. Resident identifiers: #151 and #152. Facility census: 142. Findings include: a) Resident #151 Review of Resident #151's medical record found this [AGE] year old female was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of her nursing notes revealed the following consecutive entries: - The admission nursing note, dated 11:00 p.m. on 12/10/10, stated,"... Resident appeared anxious and wanted to call her niece. The Resident (sic) phone was given to Resident and this appeared to have a calming affect (sic). ... VS (vital signs) are WNL (within normal limits) excluding pulse possibly D/T (due to) anxiety experienced when first arriving. ... Resident is A/O (alert / oriented) x's (sic) /c (with) confusion noted. ... All meds sent to pharmacy STAT and pharmacy was notified and stated they would be sent. ... There appear to be (symbol for 'no') s/s (signs / symptoms) of acute distress noted at this time. ..." - A nursing note, dated 12/11/10 at 11:45 a.m., stated,"... Alert / oriented to person, place and time, But (sic) does not answer questions appropriately. (Arrow pointing up) confusion to situation / reasons for being admitted to HL (Heartland). ..." - A nursing note, dated 12/11/10 at 11:41 p.m., stated, "OT (occupational therapy) orders noted ..." - A nursing note, dated 12/11/10 (time illegible), stated, "Res (resident) OOF (out of facility) until approx 1130 - 12 noon. Ref (refused) shower upon arrival. 'I just got back from the Hospital.' ..." - A nursing note, dated 12/13/10 at 11:45 a.m., stated, "A/O x 3 (alert and oriented to person, place, and time). Confusion noted, Demanding (sic) argumentative (illegible) meds, explained med regimen several times /s (without) success D/T confusion." - A nursing note, dated 12/13/10 at 4:30 p.m., stated, "Late entry 12/12/10 12am (sic) went to res (resident's) room to give her meds. res (sic) states 'What's this?' Explained to her that it was her night time meds. Res says 'I don't take any of that sh**! I want my nerve pill and my depression pill.' Explained to her these meds had not arrived from pharmacy. Res became upset, shouting 'What the hell is wrong with this place. The longer I'm here the worse it is.' res (sic) ref (refused) to take any meds. RN supervisor (name) answered res light right after ref meds. He spoke /c me about 'not giving her meds'. I explained situation to him, went in & offered meds again & res cont (continued) to refuse. phoned (sic) pharmacy about [MEDICATION NAME] & [MEDICATION NAME]. pharmacy (sic) states that a script is needed for [MEDICATION NAME] & [MEDICATION NAME] had been sent. ..." Review of the resident's physician orders [REDACTED]." Review of Resident #151's hospital records revealed the physician who examined her wrote in the ER, under the heading "Clinical Impression", "Anxiety / Panic Attack". She was treated with intravenous [MEDICATION NAME] and returned to the facility at approximately 11:30 a.m. on 12/11/10. Review of the admitting orders found the resident was prescribed [MEDICATION NAME] 1 mg twice-a-day (bid) for anxiety and [MEDICATION NAME] (generic name for [MEDICATION NAME]) 50 mg at bedtime for depression / anxiety. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials documented at 10:00 p.m. with the following statement, "Refused all pm (evening) meds (medications) because [MEDICATION NAME] & depression med was not available." Review of the MAR found the resident also did not receive her 9:00 a.m. dose of [MEDICATION NAME] 1 mg on 12/12/10. After her return to the nursing facility on 12/11/10 (after having been treated with IV [MEDICATION NAME] for anxiety / panic attack), the facility failed to obtain and administer two (2) consecutive scheduled doses of [MEDICATION NAME] to treat her anxiety. She did not receive her first dose of [MEDICATION NAME] at the nursing facility until the 9:00 p.m. dose was administered on 12/12/10. An interview with the DON, on 01/06/11, confirmed the facility did not obtain the resident's [MEDICATION NAME] until 9:25 p.m. on 12/12/10. -- b) Resident #152 1. Review of Resident #152's medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE]. According to recent assessment data, she was alert / disoriented to person, place, and season, had short and long-term memory impairment, and her cognitive skills for daily decision-making were moderately impaired. She was totally dependent on staff for the performance of all activities of daily living, had partial loss of voluntary movement with limitations in range of motion on both sides in her upper and lower extremities, and was incontinent of bowel and bladder. Her active [DIAGNOSES REDACTED]. Further review found the resident was receiving [MEDICATION NAME] 5 mg (blood thinner) daily, which placed her at high risk for bleeding. - Review of Resident #152's nursing notes found the resident was readmitted to the facility on [DATE], following treatment in the hospital for UTI [MEDICAL CONDITION]; her [DIAGNOSES REDACTED]. She went back out to the hospital on [DATE] for the insertion of a gastrostomy tube and returned to the facility again on the evening of 12/20/10. According to a nursing note dated 12/26/10 at 12:30 a.m., "Resident sent to (initials of local hospital) ER (emergency room ). Order received via telephone from Dr. (name of physician). See SBAR (Situation / Background / Assessment / Request form)." The next consecutive note, dated 12/26/10 at 7:10 a.m., stated, "Called (initials of local hospital) ER. Resident admitted to (initials of local hospital) D/T (due to)[MEDICAL CONDITION], mental status change, & respiratory compromise." Review of the electronic form referred to as the "SBAR", dated 12/26/10 at 12:45 a.m., found under the heading "Situation": "O2 sats (blood oxygen saturation levels) decreased to 72% with O2 @ 2.5L NC (oxygen at 2.5 liters / minute via nasal cannula). airways (sic) suctioned (sic) O2 (sic) increased to 80%. NEB (nebulizer) tx (treatment) administered. Lung sounds congested. O2 icreased (sic) to 3L via NC S (sic)." Under the heading "Background", the author noted that medical information pertinent to this event included, "Fall on 7p-7a (7:00 p.m. to 7:00 a.m.) shift on 12/24/2010, recent peg tube placement, increased temp of 101.0." The author also noted the resident had exhibited a decrease in her level of consciousness, and increased heart rate of 148 beats per minute with an irregular rhythm, wheezes when checking her lung sounds, and the resident's skin color was pale. Under the heading "Assessment (RN) / Appearance (LPN/LVN)", the licensed practical nurse (LPN) completing the form noted, "Resident (sic) skin warm, clammy. Pale in color. SOB (shortness of breath) noted." Under the heading "Request", the author noted having contacted the resident's physician and obtaining an order to "Send resident to (initials of local hospital) ER. " Review of the resident's physician progress notes [REDACTED]. ("Rhonchi" or "wheezes" are abnormal breath sounds caused by air moving through airways narrowed by [MEDICATION NAME], swelling, or partial airway obstruction.) Review of nursing notes from her previous stay, from 12/02/10 to 12/13/10, revealed the resident was congested and required suctioning and aerosolized breathing treatments, with deep suctioning and a chest x-ray ordered on [DATE]. Review of her current care plan, with a print date of 09/01/10, revealed the following problem statement: "Potential for respiratory impairment related to [MEDICAL CONDITION]." The goal associated with this problem statement was: "Resident will have no acute episodes of respiratory distress such as, but not limited to SOB, dyspnea, cyanosis, aspiration (sic)." Interventions to assist the resident in achieving this goal included: "... Monitor lung sounds and VS (vital signs) as needed. Report abnormalities to physician. ... Monitor for and report adverse changes in respiratory rate, cough, respiratory effort, sputum color / consistency. ... " Review of nursing notes from the date of her readmission to the nursing facility on 12/21/10 until her transfer to the hospital on [DATE] found no evidence to reflect the licensed nursing staff was routinely assessing / monitoring the resident's respiratory system for abnormal breath sounds after the physician identified the presence expiratory rhonchi, although the licensed staff periodically noted the resident's respiratory rate and blood oxygen saturation levels. - Further review of the resident's current care plan found the following problem statement: "Urinary incontinence related to effects of [MEDICAL CONDITION]." The goal associated with this problem statement was: "Will have no complications due to incontinence such as, but not limited to UTI, skin breakdown (sic)." Interventions to assist the resident in achieving this goal included: "...Monitor for and report any changes in amount, frequency, color or odor of urine or continency (sic). ... Monitor for and report any S&S (signs and symptoms) of UTI such as flank pain, c/o (complaints of) burning / pain, fever, change in mental status, etc ..." The medical record contained no nursing notes or other evidence that licensed nursing staff was assessing / monitoring the resident for signs and symptoms of UTI. - The resident was admitted to the hospital on [DATE] with a temperature of 101.0 degrees Fahrenheit (F); the resident's hospital [DIAGNOSES REDACTED]. - 2. Review of Resident #152's medical record found a nursing note, dated 12/05/10 at 2:30 p.m., documenting that Resident #152 sustained a witnessed fall. A nursing note, dated 12/07/10 at 10:00 p.m., documented the following, "... Resident did have a fall on 12/5/10 at 2:30 p.m. Neuro Checks started at 10 pm to rule out neurological damages..." Because of her daily use of [MEDICATION NAME], Resident #152 would have been at high risk for intracranial bleeding if she had struck her head as a result of this fall. Review of the neurological evaluation flow sheet found that nursing staff did not begin monitoring the resident for potential neurological compromise until 10:00 p.m. on 12/07/10, approximately fifty-five (55) hours after the resident's fall. In an interview was conducted on 01/07/11 at 3:45 p.m., the director of nursing (DON - Employee #15) was asked when nursing staff should have started neuro checks after the resident's fall. The DON stated that neuro checks should not have waited and staff should have started them immediately. - 3. Medical record review also revealed Resident #152 was readmitted to the facility on [DATE] at 6:30 p.m. with a [DIAGNOSES REDACTED]. Review of the MAR found Resident #152 received no [MEDICATION NAME] from her date of re-entry on 12/02/10 at 6:30 p.m. until 9:00 p.m. on 12/06/10. A nursing note, written on 12/05/10 at 5:30 p.m., documented the nurse called the medical director to inform him of the resident not receiving [MEDICATION NAME]. The note also documented the medical director instructed the nurse to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. The resident missed twelve (12) doses of ordered [MEDICATION NAME] due to the facility's failure to obtain pharmaceutical services in a timely manner. . | 2014-03-01 |