cms_WV: 3320
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3320 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 684 | K | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to administer Resident #12's and Resident #56's sliding scale insulin in accordance with the physician's orders [REDACTED].#12's blood sugar was recorded as 57. Resident #12 did not receive her sliding scale insulin coverage on 76 occasions when her blood sugar was in excess of 200 which required sliding scale coverage. This was during the time frame of 10/08/18 through current. Also on 01/25/19 the residents blood sugar was 57 and there was no evidence the facility implemented the hypoglycemic protocol. Resident #56 did not receive her sliding scale coverage on four (4) occasions when her blood sugar was in excess of 201 which required sliding scale coverage. This was from 02/09/19 through current. It was determined by the state agency (SA) that these failures place Resident #12 and Resident #56 at an immediate risk for serious harm and/or death placing Resident #12 and Resident #56 in an immediate jeopardy situation. At 12:30 p.m. on 04/09/19 the Nursing Home Administrator (NHA) and Director of Nursing (DON) was notified of the immediate jeopardy. The facility submitted a plan of correction (P[NAME]) at 1:29 p.m. on 04/09/19. The SA requested changes and new P[NAME] was submitted at 2:00 p.m The SA again requested changes and the final P[NAME] was submitted at 2:19 p.m. and was accepted by the SA at 2:27 p.m. The SA observed for implementation of the P[NAME] and determined it had been implemented. The IJ was abated at 4:50 p.m. on 04/09/19. This was true for two (2) of two (2) residents who receive sliding scale insulin coverage. After the IJ was abated a deficient practice remained therefore the scope and severity was decreased from a K to E. A deficient practice remained for Resident #35 the facility failed to ensure that the physician had provided orders for medications prior to them being administered. Finally, for Resident #54 the facility failed to respond an implement a smoking cessation program when the resident had requested one be implemented. These were all random opportunities for discovery. Resident identifiers: #12, #56, #35, and #54. Facility Census: 57. Findings included: a) Resident #12 1. Sliding Scale Insulin A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found the following physician orders: -- Order dated 10/08/18 [MEDICATION NAME] R Regular Insulin per sliding scale. 200 - 249 give 2 units, 250 - 299 give 4 units, 300 - 349 give 6 units, 350 - 400 give 8 units. BS (Blood Sugar) greater than 400 call physician. This ordered was an as needed order. -- Order dated 10/24/18 Accu Check twice daily at 6:00 a.m. and 6:00 p.m. Further review of the record found on the following occasions when Resident #12's blood sugar was elevated and she should have received sliding scale coverage and she did not: --10/08/18 - 6:01 p.m. blood sugar was 211. --10/08/18 - 8:02 p.m. blood sugar was 204. --10/10/18 - 1:11 p.m. blood sugar was 321. --10/11/18 - 8:03 a.m. blood sugar was 334. --10/11/18 - 12:09 p.m. blood sugar was 289. --10/12/18 - 8:17 a.m. blood sugar was 319. --10/12/18 - 4:27 p.m. blood sugar was 317. --10/12/18 - 8:13 p.m. blood sugar was 288. --10/14/18 - 2:58 p.m. blood sugar was 398. --10/16/18 - 8:03 a.m. blood sugar was 337. --10/16/18 - 5:10 p.m. blood sugar was 282. --10/16/18 - 8:19 p.m. blood sugar was 318. --10/21/18 - 7:49 p.m. blood sugar was 365. --10/22/18 - 8:45 p.m. blood sugar was 311. --10/23/18 - 8:46 p.m. blood sugar was 392. --10/24/18 - 4:47 a.m. blood sugar was 226. --10/24/18 - 9:46 a.m. blood sugar was 372. --10/24/18 - 6:09 p.m. blood sugar was 331. --10/26/18 - 5:37 p.m. blood sugar was 203. --10/29/18 - 5:07 a.m. blood sugar was 230. --10/30/18 - 5:44 a.m. blood sugar was 223. --10/31/18 - 5:34 p.m. blood sugar was 379. --11/02/18 - 5:52 p.m. blood sugar was 324. --11/05/18 - 9:09 p.m. blood sugar was 232. --11/12/18 - 5:54 a.m. blood sugar was 230. --11/12/18 - 8:00 p.m. blood sugar was 286. --11/13/18 - 5:24 p.m. blood sugar was 313. --11/14/18 - 5:06 a.m. blood sugar was 233. --11/16/18 - 5:27 a.m. blood sugar was 342. --11/17/18 - 5:04 a.m. blood sugar was 226. --11/17/18 - 5:25 p.m. blood sugar was 222. --11/19/18 - 5:05 a.m. blood sugar was 203. --11/20/18 - 5:46 p.m. blood sugar was 270. --11/21/18 - 5:24 p.m. blood sugar was 360. --11/23/18 - 5:03 p.m. blood sugar was 284. --11/24/18 - 5:13 p.m. blood sugar was 240. --11/25/18 - 5:13 a.m. blood sugar was 221. --11/26/18 - 5:53 p.m. blood sugar was 290. --11/28/18 - 5:01 p.m. blood sugar was 266. --11/30/18 - 5:30 a.m. blood sugar was 268. --11/30/18 - 5:01 p.m. blood sugar was 232. --12/03/18 - 5:09 p.m. blood sugar was 400. --12/07/18 - 5:14 p.m. blood sugar was 261. --12/09/18 - 5:07 a.m. blood sugar was 279. --12/09/18 - 5:35 p.m. blood sugar was 262. --12/15/18 - 6:01 a.m. blood sugar was 238. --12/19/18 - 5:12 p.m. blood sugar was 331. --12/22/18 - 5:42 p.m. blood sugar was 284. --12/23/18 - 5:57 p.m. blood sugar was 252. --12/25/18 - 6:05 a.m. blood sugar was 213. --12/26/18 - 5:15 a.m. blood sugar was 239. --12/27/18 - 9:43 a.m. blood sugar was 240. --12/27/18 - 5:15 p.m. blood sugar was 214. --12/28/18 - 5:45 a.m. blood sugar was 208. --12/31/18 - 5:16 p.m. blood sugar was 271. --01/01/19 - 5:34 a.m. blood sugar was 214. --01/03/19 - 7:19 p.m. blood sugar was 244. --01/04/19 - 5:06 a.m. blood sugar was 234. --01/05/19 - 5:10 p.m. blood sugar was 232. --01/06/19 - 5:00 p.m. blood sugar was 208. --01/11/19 - 5:05 p.m. blood sugar was 219. --01/13/19 - 5:28 p.m. blood sugar was 217. --01/19/19 - 5:08 p.m. blood sugar was 245. --01/23/19 - 5:24 p.m. blood sugar was 250. --01/25/19 - 5:38 p.m. blood sugar was 245. --01/26/19 - 5:45 a.m. blood sugar was 226. --01/31/19 - 5:34 p.m. blood sugar was 236. --02/06/19 - 5:24 a.m. blood sugar was 205. --02/19/19 - 5:16 p.m. blood sugar was 200. --02/24/19 - 6:38 p.m. blood sugar was 200. --03/07/19 - 5:00 a.m. blood sugar was 274. --03/11/19 - 6:18 p.m. blood sugar was 210. --03/12/19 - 5:04 a.m. blood sugar was 209. --03/26/19 - 5:07 a.m. blood sugar was 244. --04/02/19 - 5:09 p.m. blood sugar was 203. --04/07/19 - 5:46 a.m. blood sugar was 302. --04/08/19 - 5:06 a.m. blood sugar was 221. Review of the Medication Administration Record (MAR) found Resident #12 did not receive any sliding scale insulin on the above mentioned dates. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #12's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. 2. Diabetic Protocol (Hypoglycemic Incident) A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found Resident #12's blood sugar was only 57. A review of the facility's Diabetic Protocol found the following, .If Glucose less than 60: If Resident is conscious, cooperative, and able to take fluids by mouth: -- Administer *(1) one full tube of glucose paste per package directions. Repeat glucose in 15 minutes. If glucose still less than 60, and resident remains stable as above repeat administration with another full tube of glucose paste (MONTH) give a total of 3 glucose pastes following same protocol before notifying physician. Recheck glucose in 15 minutes. If glucose greater than 60 with resident stable, notify physician on next facility round. Hold Scheduled insulin and oral hypoglycemic's until glucose greater than 200. Monitor glucose every 30 minutes time four (4), then every hour for two hours Further review of the medical record found no evidence the hypoglycemic protocol was ever implemented. An interview with the DON at 11:00 a.m. on 04/09/19 confirmed the hypoglycemic protocol was not implemented when the residents blood sugar was less than 60. b) Resident #56 A review of Resident #56's medical record at 10:00 a.m. on 04/09/19 found the following physician orders: -- Order Dated 04/28/18 which read Blood Sugar checks once a day at 7:00 p.m. This was an active order at the time of this review. -- Order dated 03/23/18 which read [MEDICATION NAME] R per sliding scale coverage if blood sugar is 201 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units, 401 - 450 give 14 units, 451 - 500 give 20 units, if blood sugar is greater than 500 call doctor. Further review of the record found on the following occasions when Resident #56's blood sugar was elevated and she should have received sliding scale coverage and she did not: -- 02/27/19 - 7:50 p.m. blood sugar was 278. -- 03/29/19 - 9:11 p.m. blood sugar was 235. -- 04/01/19 - 9:19 p.m. blood sugar was 236. -- 04/03/19 - 8:56 p.m. blood sugar was 231. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #56's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. c) Facility's Plan of Correction The facility's plan of correction read as follows: 4-9-19 Physician order [REDACTED].#56 and #12 and to monitor glucose checks BID for 14 days, if less than 250mg/dL then decrease to 3 times a week. All licensed nursing staff in the building beginning 4-9-19, will be educated regarding use of Diabetic Protocol, followed by education provided during shift change to all incoming licensed nursing personnel and will continue until all licensed personnel have been educated. Daily audit for four weeks, then a weekly audit four weeks, followed by a random audit to be reviewed in morning meeting and in facility Quality Assurance meetings on any resident receiving sliding scale insulins. d) Resident #35 Review of the medical record found the resident was admitted to the facility on [DATE]. On 03/25/19, the resident returned to the facility from an outpatient procedure with the urologist. The facility had orders to hold the resident's Aspirin (ASA) and Eliquis 7 days prior to the procedure. The medication was held as directed. When the resident returned to the facility, the physician wrote hand written orders for, (MONTH) resume ASA and Eliquis when urine output is clear. Record review found a nurses note dated 03/25/2019 at 5:11 PM. Resident returned from (name of hospital/name of physician) at approximately 4:45 p.m. via (name of ambulance) wheelchair van without incident. Returned with two scripts. Keflex 500 mg one capsule PO (my mouth) Q (every) 8 hrs (hours) x 5 days. [MEDICATION NAME] 10 mg one tab PO QHS. Return appt. (appointment) Monday, (MONTH) 27, 2019 at 10:30 a.m. (MONTH) resume all meds except for anticoagulant medication, may resume that after urine clears up. A second nurses note dated 03/26/19 at 12:55 PM, .Resident had only voided once since returning from (name of hospital) as of medication pass time this AM. Urine is now clear and can resume ASA and Eliquis tomorrow. Review of the medication administration record found the medication was resumed. On 04/10/19 at 9:20 AM, the Director of Nursing (DON) was asked if a nurse can prescribe a medication without calling the physician for orders? The DON said the nurse would have looked at the resident's urine before resuming the medication. The DON could not find any evidence the physician was contacted and told by the nurse the urine was clear so the physician could order the medications ASA and Eliquis to be resumed. The DON was unable to verify how the nurse determined the urine was clear. The Resident's minimum data set (MDS) with an Assessment Reference Date (ARD) of 03/11/19 noted the resident was frequently incontinent of urine. e) R54 During a medical record review on 04/08/19 for R54 revealed the care plan had an approach to encourage resident to stop smoking and offer smoking-cessation assistance as desired, consult physician for nicotine patch/gum or other medication as needed. Further review of the Observation Book for the physician had a note on 01/02/19 for R54: Patient has agreed to try and quit smoking would like to start with low dose Nicotine Patch and decrease smoking gradually. In an interview with the director of nursing (DON) on 04/10/19 at 1:20 PM, she was unable to locate any evidence that R54 had been offered any smoking-cessation assistance to help her to decrease smoking. | 2020-09-01 |