cms_WV: 11441
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11441 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2011-01-25 | 309 | G | 65CW12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records (both electronic and paper), staff interviews, review of in-service records, review of disciplinary action documents, review of controlled substances records, review of the facility's documentation regarding falls, review of the facility's investigations of falls and reportable events, and observations, the facility had failed to ensure a resident received appropriate and timely interventions for management of the onset of pain. The lack of pain management constituted actual harm to the resident. Review of documentation found a resident had sustained falls in December 2010. The last fall was noted to have occurred on 12/25/10. She later began to demonstrate both verbal and non-verbal indicators of pain. During this time, she also began to exhibit a limp and a decreased effort to ambulate. The onset of pain symptoms was evident beginning on the late morning of 12/31/10. A total of six (6) doses of Tylenol 650 mg were documented as given. The effectiveness of those doses was not documented (or documented in the negative), and documentation indicated the resident's pain symptoms persisted. The physician saw the resident in the afternoon on 12/31/10. He noted the resident was crying but did not order any additional pain medication. There was no evidence further treatment of [REDACTED]. On 01/02/11 at 23:39 (11:39 p.m.), the resident was sent to the hospital where it was found she had a [MEDICAL CONDITION]. Through review of medical records, review of the controlled substances sign-out book for Mary's Garden, staff interviews, observations, and review of documentation of in-services and disciplinary actions, it was determined the facility had identified and addressed the deficits in the provision of care related to pain management for Resident #50. This deficient practice was determined to constitute past noncompliance as it occurred after the last standard survey (completed on 09/25/09) and before the start of this on-site revisit to a complaint investigation on 01/24/11. Resident identifier: #50. Facility census: 84. Findings include: a) Resident #50 During review of occurrences reported to the State in accordance with the ?483.13(c)(1)(ii), it was noted a report had been completed for Resident #50 on 01/03/11. The report indicated the resident had an injury of unknown source. She had been sent to the emergency room for complaints of pain, where she was found to have a displaced [MEDICAL CONDITION] hip. Record review revealed this [AGE] year old female resident had [DIAGNOSES REDACTED]., and dementia with behavioral disturbances. -- 1. Review of the nursing entries and assessments found she had fallen on 12/09/10. A nursing entry for 12/09/10 at 18:09 (6:09 p.m.), by Employee #111 (a licensed practical nurse (LPN)) noted the resident had fallen in the last 72-hours. She had experienced a witnessed fall at the nurses' station. At that time, the resident was not exhibiting signs and symptoms of pain according to the nurse. A late entry on 12/10/10 at 2:09 (the author did not indicate the date or time of the original event for which this late entry was made), made by an LPN, noted the resident was ambulatory for short distances that morning. She was also noted to be unsteady of gait at times. On 12/12/10 at 13:14 (1:14 p.m.), Employee #29 (an LPN) noted the resident had fallen. The resident had been ambulating in the common area of the unit. The nurse wrote (excerpts typed as written), "... (Resident's name) is experiencing pain. right hip sore-per resident. ..." On 12/12/10 at 21:14 (9:14 p.m.), Employee #29 wrote the resident was resting in bed at that time. The note included (excerpts typed as written), "Cont(inue) to monitor for bruising/ c/o's (complaints of) pain." On 12/13/10 at 10:29 (8:29 p.m.), Employee #29 noted the resident was sitting in the common area with other residents. It was also noted, "Ambulating slow-gait steady at this time." The next nursing entry was at 19:57 (7:57 p.m.) on 12/19/10 by Employee #29. The resident was note to be ambulating in the common area. She refused to sit down or use a wheelchair. Her gait was noted to be unsteady. On 12/22/10 at 4:38 (4:38 a.m.), Employee #64 (an LPN) noted by that a body audit had been completed with no new areas found. On 12/27/10 at 16:12 (4:12 p.m.), Employee #29 noted the resident was ambulating with an unsteady gait. It was also noted staff had assisted the resident with ambulating several times that day. The nurse wrote (excerpts typed as written), "Res(ident) will sit for a few min's (minutes) then gets up and ambulates." On 12/29/10 at 10:17 (10:17 a.m.), Employee #49 (the director of nursing (DON)), spoke with the resident's son about the resident's lethargy and falls risk. The son stated he would rather not have a lap buddy or seat belt used at that time. Her medications were also discussed with the son - that [MEDICATION NAME] had been discontinued due to the possible side effect of muscle spasms. The psychologist had changed the resident's medication to [MEDICATION NAME], and she appeared to be a little more lethargic. Dosage reduction was to be discussed with a psychiatrist. The next entry was at 15:33 (3:33 p.m.) on 12/31/10 by Employee #113 (an LPN), who wrote (excerpts typed as written), "Res c\o severe pain to R(ight) leg\knee. Visible signs of pain present: teary eyes, moaning\guarding area with movement. This nurse administered Tylenol per standing order. RN supervisor notified and assessed area. Dr. (name) present new orders received for X-ray to R knee and R femur. (X-ray supplier) notified and X-rays ordered STAT (immediately)." On 12/31/10 at 16:33 (4:33 p.m.), it was noted the x-rays had been completed. On 12/31/10 at 22:24 (10:24 p.m.), Employee #64 (an LPN), wrote (excerpts typed as written), "Res c\o severe pain to R leg\knee. Visible signs of pain present: teary eyes, moaning \ guarding area with movement. This nurse administered Tylenol per standing order. X-ray result from (x-ray supplier) are unremarkable. Dr. (name) notified." On 01/01/11 at 04:54 (4:54 a.m.), Employee #113 (an LPN) wrote (excerpts typed as written), " Resident continues to complain of severe R knee and leg pain. Tylenol given per standing order. Will continue to monitor." On 01/01/11 at 09:33 (9:30 a.m.), Employee #113 noted (excerpts typed as written), "Res cont to c\o pain to R knee \ leg. Tylenol per standing order administered at this time." On 01/02/11 at 06:32 (6:32 a.m.), Employee #114 wrote (excerpts typed as written), "Res had c/o pain upon waking this am. Tylenol gave at 6am. Will cont to monitor." In the next entry, at 18:54 (6:54 p.m.) on 01/02/11, Employee #111 (an LPN) wrote (excerpts typed as written), "Resident had continued throughout the day to exhibit s/sx (signs/symptoms) of pain ( facial grimace, moaning, tears) and grabs at right hip when staff attempt to help reposition her. Resident denies pain and states she doesn't know what to do, as explaination as to why she was crying. Spoke with Dr. (name) who ordered STAT xrays of her right pelvis and right hip. [MEDICATION NAME] 5/500mg one by mouth every four hours as needed. Dr. (name) to call in the medication to the pharmacy, have contacted (x-ray supplier) for STAT x-rays. Son, (son's name) notified of n/o's (new orders). ..." The x-rays were noted to have been completed at 21:17 (9:17 p.m.) on 01/02/11. At 23:39 (11:39 p.m.) on 01/02/11, Employee #111 noted the x-ray had shown a "right displace [MEDICAL CONDITION]." She wrote the resident was transferred to the hospital for evaluation and treatment. -- 2. Review of the statements taken during the facility's investigation of the resident's fracture (written as faithfully to the original as possible, with the statements of some individuals having been broken into segments in order to place them in chronological order) found the following: 12/25/10 - Employee #99 (a nursing assistant - NA) - "... Resident was lethargic mood, resident when gotten up in wheel chair, attempted getting up and walking. When she did attempt to walk had a limp on right side, didn't seem to be in pain. Resident wasn't on feet for any length of time because of possible falling on X-mas day. Resident seemed very lethargic for several days, wouldn't hardly eat or drink. Resident seemed to want to sleep a lot... I worked on 12/25/26/28/29/30/31/1 On these days (Resident's name) got out of bed most days between 9 A and 11 A then on Fri, 31st she slept later than usual when resident finally got out of bed she states she was hurting on right side & started crying." 12/31/10, night shift - Employee #105 (NA) - "(Resident's name) was lying in bed awake all night. My self and nurse kept going in there to check on her. When straightened up in bed, resident would turn back to her one side facing the door. The nurse asked her if she was in pain, resident stated that it was never ending. ..." 12/31/10, days / evenings - Employee #113 (LPN) - This nurse noted the resident had slept later than usual. "... the CNA's reported to me the pt was in pain when they brought her into the common's area. Upon assessment, pt had visible s/s of pain. She was holding her right knee, had tears in her eyes and was shaking. I administered Tylenol per physician's standing order. I then call Rehab unit for an RN to come over and assess pt. (Employee #60), RN assess pt. right leg and knee. She stated she would ask Dr. (name) to come over since he was in the building. Dr. (name) came over about 20-30 mins later and examined pt. He ordered a STAT x-ray of right knee and femur. ... completed x-ray around 4:30 p.m. ..." 12/31/10, day shift - Employee #26 (NA) - "On Friday 12-31-10 on 2:00 p rounds (Resident's name) was still in bed. Another aid & I got her up. She would not put any weight on her (R) side. She was tearful and complained of pain while holding her (R) knee. I asked her where she was hurting & she said everywhere. ..." 01/01/11, night shift - Employee #20 (LPN) - This nurse noted the evening shift nurse had told her the resident had been complaining of pain and she had been given Tylenol. "...was in the bed, she was restless during the night but did not attempt to get out of bed. Around 6am this nurse and CNA (Employee 37) went in to do last round on resident. After she woke up she had a grimace on her face. I asked resident if she was in pain and she said 'yes.' We asked her to show us where she was hurting and resident stated 'All over.' I lifted residents R Leg to put on a sock and resident grabed her R side. I went and got resident some Tynenol per standing order . . . I asked the oncoming nurse if she could try to get (Resident's name) something stronger for pain and I told her how she had grabed at her R side when I lifted her leg." 01/01/11, day shift - Employee #26 (NA) - "On Saturday 1-1-11 she complained of being in pain all day & refused to eat. . . ." 01/01/11, days / evenings - Employee #113 (LPN) - "... Tylenol administered at 9:30am with am meds. Pt was holding her right knee and had tears in her eyes. ..." 01/01/11, evenings / nights - Employee #37 (NA) - "... At around 4 pm I helped take her to the bathroom, it took two of us because She was telling us the She couldn't stand because She was hurting. I asked what was hurting her and She said 'I'm hurting all over' . She was like that for most of the rest of the shift, tearful and had a pained look on her face... She was up most of the night on the 11-7 shift. She never tried to get out of bed, but She was restless and saying she was hurting. At around six Sunday morning, (Employee #20), LPN & I went in to do our last round and She had finally went to sleep, upon checking her for incontinence she woke up and I asked her if she was still hurting and she said she was. When (Employee #20) picked up her right foot to put her sock on, she grabbed her right leg and grimaced. We asked her where she was hurting and again She said 'All over'. We checked her all over real good while dressing her and found no abrasions or bruised other than two small faint ones on her right buttocks... (Employee #20) gave her some Tylenol. While sitting there, she fell back asleep but still had a pained look on her face. ... " 01/01/11 - Employee #32 - "On Jan. 1 & 2, I noticed that (Resident's name) was in intense pain. She was crying about her hip. Staff was aware of this. (Resident's name) did not stand and was watched closely watched in her wheelchair. On December 30, (Resident's name) was up in her wheelchair & made no attempts to get up that day." 01/01/11 - Employee #104 (NA) - "... was in bed complaining of leg pain, after, getting up she complained more to the point of not eating and crying. ..." Employee #104 also noted the resident could not stand on her leg. 01/02/11 - Employee #32 - "On Jan. 1 & 2, I noticed that (Resident's name) was in intense pain. She was crying about her hip. Staff was aware of this. ..." 01/02/11, day shift, Employee #26 (NA) - "... On Sunday 1-2-11 she still complained of being in pain all day long." 01/02/11 - Employee #104 (NA) - "... Cryed in bed and after getting in wheelchair. She was so miserable and crying in pain we put her in the recliner in the common area. She could not stand on her leg either day." 01/02/11 - days / evenings, Employee #111 (LPN) - "... Resident slept until right before lunch in the recliner chair. When (Resident's name) woke up, she was tearful, but when I asked her if she was hurting, she said 'no'. I asked her in several different ways if she was hurting, but she kept denying pain and stated, 'I just don't know where I am or what I'm supposed to do.' ... Throughout the shift, I administered Tylenol to (Resident) as ordered just to be sure that she wasn't experiencing pain. The Tylenol did not affect her tearfulness." She also noted she had tried to contact Dr. (name) at 1400 (2:00 p.m.), but contact was not made until 1830 (6:30 p.m.) She told him about the resident's "persistent tearfulness and guarding when awake. ..." An x-ray was ordered and at approximately 2330 (11:30 p.m.) received x-ray reports that the resident had a displaced [MEDICAL CONDITION] hip, and she was transferred to the hospital. 01/02/11, evenings / nights - Employee #37 - "I came back on at 3pm, (Resident's name) was asleep in beige recliner. She slept most of the evening but kept her hand on her right leg. She was gotten up and toileted before dinner, took 2 of us just like the night before. She ate (was fed) very little dinner saying she was tired of hurting and had tears in her eyes. This aide did not put her to bed but as I was putting her roommate to bed, she was lying in bed and crying, saying, 'I can't take this pain anymore'. After finishing with her roommate, I checked on her, tried to reposition her to make her a little more comfortable but nothing really helped. After that we kept making 15 min - ? hr checks on her until she was sent out." 01/02/11, night shift - Employee #20 (LPN) - "I came back in Sun night (1-2-11) for 11-7 shift. The nurse (nurse's name) that worked that day + evening gave report on (Resident's name). She said that she had got a order for [MEDICATION NAME]. I received a phone call about the x-rays and that (Resident's name) (R) hip was broken. ..." The resident was sent out to the hospital. -- 3. The physician's progress note for 12/31/10 included, "C/O pain (R) thigh & knee area. (Symbol of 'no') knee swelling. Able to extend knee. No perceptible tenderness but the pain is really hurting her/c crying, etc." -- 4. Review of the medication administration records found she had been given Tylenol, according to the front sheet of the medication administration records (MAR) as follows: on 12/31/10 at 2:00 p.m. and 9:00 p.m.; on 01/01/11 at 3:30 a.m., 9:30 a.m., and 5:00 p.m.; and on 01/02/11 at 6:00 a.m., 9:00 a.m., and 3:00 p.m. This was a total of eight (8) doses. - The back of the MARs indicated the resident received Tylenol for pain as follows: On 12/31/10: - At 2:00 p.m. for "C/O pain (R) knee/leg", with no results documented - At 9:00 p.m. for "C/O pain (R) knee/leg", with the results charted as "(-)" (a minus sign that was circled) On 01/01/11: - At 3:30 a.m. for "C/O (R) knee & leg pain, with the results charted as "(-)" - At 9:30 a.m. for "C/O (R) leg/knee pain", with no results charted - At 5:00 p.m. for "C/O (R) leg/knee pain", with no results charted On 01/02/11: - At 6:00 a.m. for "C/O (R) leg pain", with the results charted as "(-)" This was a total of six (6) doses. - On 01/24/11 at 6:05 p.m., Employee #29 (LPN) was asked about the minus signs. She said, "If you don't get a plus you need to do something else." Review of the nursing entries and MARs, regarding the administration of Tylenol, found it was given regardless of the severity of the pain. The pain was not rated consistently, and there were only three (3) of eight (8) doses that had been evaluated for effectiveness. The physician's orders [REDACTED]." However, it was not noted the resident complained of a headache during this time. Tylenol is for mild to moderate pain. Although the resident was noted to have severe pain at times, there was no evidence staff contacted the physician for an [MEDICATION NAME] that would control the resident's pain. According to the controlled medication book, the [MEDICATION NAME] had arrived at 11:00 p.m. on 01/02/11. No doses were signed out in the book, nor charted on the Medication Administration Record, [REDACTED] -- b) Evidence of the facility's identification and correction of the deficient practice related to pain management 1. On 01/24/11 at approximately 6:15 p.m., the director of nursing (DON) provided copies of two (2) "One on One Education" forms. One (1), date 01/07/11, was for Employee #56 (an RN). The concern was "not adequately assessing resident for pain or pain relief. Pain assessment and change of condition not initiated /c (with) new onset of pain." The corrective action needed to remedy concerns: "Must ensure that all resident are as free of pain as possible. Must complete pain assessment & change of condition /c any new onset of pain. Must notify physician of resident need and obtain adequate medication." Another education form was completed on 01/07/11 for Employee #113 (an LPN). It had essentially the same information as the other. As the DON pointed out, the RN was responsible for assessing resident and the LPN was responsible for evaluation of the resident. The DON said another form had been completed for another nurse, but she was unable to locate that document prior to exit. -- 2. The DON also provided a copy of an in-service on "Pain Management" that had been provided to staff. This addressed evaluation of pain, notification of the physician, continued assessment of the resident for the presence of pain - either verbal or observation of non-verbal indicators, documentation of evaluations, care planning, assessment and documentation of the effectiveness of pain interventions, notification of the physician when pain medications were ineffective, and so on. -- 3. The administration of pain medications to Resident #50 after her return from the hospital was reviewed. Page 204 of the "Controlled Substances Book" indicated she received [MEDICATION NAME] 5/500 at 9:00 p.m. on 01/13/11. She received a total of three (3) doses of [MEDICATION NAME] at this dosage. Page 206 indicated she received [MEDICATION NAME] 10/500 for two (2) doses on 01/19/11 and five (5) doses on 01/20/11, then it was discontinued. Page 211 of the book indicated she had been started on [MEDICATION NAME] 12 mcg patches. These had been applied on 01/21/11 and 01/24/11. Page 212 indicated the resident had been started on [MEDICATION NAME] 5/325. She received four (4) doses on 01/21/11, four (4) doses on 01/22/11, two (2) doses on 01/23/11, and two (2) on 01/24/11. -- 4. The controlled substances book was randomly reviewed with regard to the administration of [MEDICATION NAME]. No issues related to usage were noted. -- 5. The resident was observed in the common area of Mary's Garden on 01/25/11, after lunch. She did not appear to be in pain or exhibit non-verbal indicators of pain. Other residents in the common area were randomly observed and none demonstrated any indicators of pain. General observational tours of the other units did not find any visual or auditory indicators of residents experiencing pain or discomfort. -- 6. The records of Residents #41 and #53, both had sustained falls, were reviewed. No issues related to pain management were found. -- 7. On 01/25/11 at 12:42 p.m., the DON said they had done pain assessments on everyone in the building after the occurrence with Resident #50. -- 8. Based on the staff interviews, observations, review of medical records, and review of other facility documents, it was determined the had identified the deficits in care provided to Resident #50 with respect to assessment of her pain, relevant documentation, administration of [MEDICATION NAME], evaluation of the efficacy of [MEDICATION NAME], notification of the physician, and other related aspects of pain management. Staff had been provided with needed training and those involved had been given one-on-one educational counseling. It was therefore determined the facility had identified the deficient practice and implemented corrective actions to prevent recurrence. No additional deficient practices were identified. Therefore, this citation constitutes past noncompliance with the requirements at ?483.25 - Quality of Care. | 2014-03-01 |