cms_WV: 3321
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3321 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 697 | D | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to provide appropriate pharmacological interventions in accordance with physician's orders [REDACTED]. Resident identifier: #27. Facility census: 57. Findings included: During initial resident screening on 04/08/19 at 12:49 PM, Resident #27 stated My tail bone hurts me when I am up in my wheelchair for a long time, and sometimes my neck hurts. I used to take Tylenol at home, and it helped. Not sure if I am getting it here. Resident has been deemed by the facilily's attending physician to have capacity to make her own decisions, and a Brief Interview for Mental Status (evaluation aimed at evaluating aspects of cognition in elderly patients) score of 15(highest score possible) out of 15 indicating intact cognitive response. Review of Medication Administration Record [REDACTED]. Progress note dated 03/01/19 by Registered Nurse (RN) #38 documented the following (typed as written): Resident up in bed watching TV. C/o (complain of) pain to right side of neck states she slept wrong. States there is a knot there. This nurse could not feel a knot in this area. Long LPN informed of need for pain medication. She states she [MEDICATION NAME] home to sleep and hasn't been sleeping well here. Will put on doctors board (observation book for facility's provider) . On 04/09/19 at 11:27 AM, review of med record revealed resident does not have any current pharmacological orders for pain. Resident's care plan was silent for pain managment interventions. On 04/09/19 at 4:45 PM Licensed Practical Nurse (LPN) #30 verified that the Resident (MONTH) #27 does not have an order for [REDACTED]. Review of medial record on 04/09/19 at 4:42 PM revealed progress note dated 03/01/19 entered by Registered Nurse (RN) #38 that documented the following (typed as written): Resident up in bed watching TV. C/o (complain of) pain to right side of neck states she slept wrong. States there is a knot there. This nurse could not feel a knot in this area. Long LPN informed of need for pain medication. She states she [MEDICATION NAME] home to sleep and hasn't been sleeping well here. Will put on doctors board (observation book for facility's provider) . At 4:50 PM on 04/09/19 review of Observation Book for the facility's attending physician revealed an entry dated 03/01/19 written by RN #38 that stated the following (typed as written): (Resident #27) takes Tylenol for arthritis at home. C/O(complained of) neck pain. Also [MEDICATION NAME] home for [MEDICAL CONDITION]. Here she has 2 tabs = 6mg [MEDICATION NAME]. On 04/10/19 at 9:18 AM during an interview the facility's attending physician verified that the check mark in the doctor's response column within the observation book log for communication regarding the resident with an entry date of 03/01/19 was his check mark and that it indicated he acknowledged the nurses request for Tylenol and [MEDICATION NAME] and he authorized those medications to be given. The facility's attending physician stated, It was also verbally presented to me the resident took these medications at home and I authorized the mediations to be continued, and to use [MEDICATION NAME] in the place of the Ambien. I don't know why the Tylenol was never ordered or given for pain, it should have been. | 2020-09-01 |