cms_WV: 11532
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
11532 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-11-03 | 514 | D | GVP312 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure an accurate and complete medical record by failing to transcribe a physician's phone order into the correct locations on the medical record which resulted in confusion during the investigation of a potential medication error in the treatment of [REDACTED]. Resident identifier: #7. Facility census: 113. Findings include: a) Resident #7 A review of the medical record revealed Resident #7 was a [AGE] year old female who received [MEDICATION NAME] daily for control of a [MEDICAL CONDITION] disorder. A recent hospitalization resulted in new medication orders when she was readmitted to the facility. When readmitted on [DATE], the physician ordered: "[MEDICATION NAME] (125 mg/5 ml) 7.5 ml TID (3 times daily) PO (by mouth) and [MEDICATION NAME] 5 ml Q HS (at bedtime) PO." On 09/30/10, these orders were changed. All previous [MEDICATION NAME] orders were discontinued, and the physician ordered: "[MEDICATION NAME] 7.5 ml @ 8:00 a.m.; 5 ml @ 12:00 p.m.; and 7.5 ml @ 4:00 p.m. PO." On 10/21/10, the laboratory results showed a drop in the resident's serum [MEDICATION NAME] level, and when the physician was notified, documentation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] (125 mg/5 ml) 5ml Q HS PO." There was no evidence in the physician's orders [REDACTED]. During an interview with the nurse (Employee #7) at 2:30 p.m. on 11/02/10, she stated, after reviewing the record, that she was the nurse who had reported the laboratory values to the physician's office and received the new order, which she had placed on the MAR, but she had failed to transcribe the order onto the physician's orders [REDACTED]. | 2014-01-01 |