cms_WV: 3394
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3394 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 684 | E | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical 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 ensure [MEDICATION NAME] (PT) and International Normalized Ratio (INR) testing was obtained according to the physician orders [REDACTED].#101, #47, and #37. These residents were receiving the anticoagulation medication [MEDICATION NAME]. Four (4) out of four (4) residents in the facility receiving [MEDICATION NAME] were affected. Facility identifiers: #72, #101, #47, #37. Facility census: 108. Findings included: a) Resident #72 On 11/30/18, Resident #72's physician wrote an order for [REDACTED].#72's medical records demonstrated that INR testing was not performed on the following dates: 12/21/18, 12/25/18, 12/26/18, and 12/30/18. On 01/17/19, Resident #72's physician changed the order from daily INR testing to weekly PT/INR testing. Review of Resident #72's medical records demonstrated that PT/INR testing was last performed on 01/16/18. On 01/30/19 at 1:33 PM, Registered Nurse (RN) #13 confirmed INR testing had not been performed for Resident #72 on 12/21/18, 12/25/18, 12/26/18, and 12/30/18. RN #13 also confirmed Resident #72 had not had PT/INR testing since 01/16/19. He stated stat PT/INR testing would be performed. On 01/29/19, this surveyor requested the facility's Director of Nursing (DoN) to provide a copy of Resident #72's Medication Administration Record [REDACTED]. Resident #72's central line was a peripherally inserted central catheter (PICC) line inserted in his arm for intravenous antibiotics and fluid. The MAR indicated [REDACTED]. The dates 01/11/19 through 01/21/19 had either nurse initials or check marks for this order. The dates 01/21/19 through 01/24/19 and 01/26/19 through 01/28/19 contained no nurse initials or check marks. On 01/31/19 at 8:48 AM, Licensed Practical Nurse (LPN) #72 and #64 were interviewed regarding Resident #72's PICC line care. LPNs #72 and #64 stated they did not know what the check marks meant on the MAR. This surveyor also noticed additional check marks had been placed on the MAR for the order, Change positive pressure cap(s) every 72 hours and as needed with each catheter change. The dates 01/21/19 through 01/24/19 and 01/26/19 through 01/28/19 now contained check marks, when they previously did not. A copy of the updated MAR indicated [REDACTED]. During an interview on 01/31/19 at 9:18 AM, the Director of Nursing and Regional Nurse Consultant were shown additional check marks had been made on Resident #72's MAR between the time the MAR indicated [REDACTED]. The Director of Nursing and Regional Nurse Consultant had no further information regarding the matter. During this interview, the Director of Nursing was also questioned regarding whether a check mark means the pressure cap was changed on that day or whether a check mark means the cap was present and intact. The Director of Nursing stated she could not identify from the MAR indicated [REDACTED]. She acknowledged initialing the MAR indicated [REDACTED]. b) Resident #101 After a review of medical records, it was discovered that Resident # 101 was ordered to have a [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) (used to monitor how well the blood-thinning medication in working) drawn every month for the [DIAGNOSES REDACTED]. She receives [MEDICATION NAME] 4 mg (a blood-thinner). Review of medical records revealed she had a PT and INR done on 11/27/18, the lab draw was due to be done again on 12/27/18. No record could be found of this being done. In the month of January, a due date of 01/07/19 was listed and a completed date 01/18/19, but the facility could not provide any results. During an interview on 01/30/19 at 9:28 AM, Unit Manager #75 was asked for the results for PT and INR for Resident # 101. On 01/30/19 at 3:05 PM, Unit Manager #13 provided a nursing note that was printed from the electronic chart. The nursing note read: Res refused lad draws this am, states she only wants them done in the hospital. This note did not say that the Attending Physician was notified. Upon review of the electronic record it was discovered, that it was a late entry note was created on 1/30/19 at 10:26 AM, 23 days after the date the physician ordered the lab work. Standards of practice is a late entry cannot be made after 24 hours. During an interview on 01/30/19 at 03:38 PM, Unit Manager (UM) #75 and Licensed Practical Nurse (LPN) #68 was asked about a nurse note that was printed that stated Resident # 101 refused a lab draw on 1/7/19. LPN #68 stated that he wrote the noet. He was asked why was the nurses note was not wrote until today at 10:26 AM, if it occurred 23 days ago after the encounter. He said because I was there that day. He was asked if the Physician was notified. He did not answer. Both UM #75 and LPN #68 were asked how much time can pass before it is too late to make a late entry note. LPN #68 stated he did not know UM #75 stated 24 hours. UM #75 was asked if she had any results or reliable information about the missing lab for the month of (MONTH) and she shook her head no. c) Resident #37 During a review of records, it was discovered that Resident #37 was ordered to have a lab draw for a PT and INR every month. On 12/06/18 only the INR results could be found. On 01/30/19 at 9:28 AM, UM #75 was asked if she could find out why only half of the order was completed. During an interview on 01/30/19 LPN# 65 stated that the machine that they were using to check the PT and INRs was using broke and it would only give results for the INR. d) Resident #47 Review of the current Medication Administration Record [REDACTED]. On 01/30/19 at 8:01 AM, the residents Licensed Practical Nurse (LPN), #65 said the resident is to have a PT/INR completed weekly according to the physician's orders [REDACTED]. Review of the PT/INR flowsheet for (MONTH) (YEAR) and (MONTH) 2019, with LPN #65 found on 12/10/18 only an IRN had been obtained. The PT was not obtained. LPN #65 said the facility has their own testing machine. There was a problem with the machine. An error message came up that day when I tried to get the PT reading. A PT/INR was performed on the week prior on 12/03/18 and the week following 12/17/18. On 01/30/19 at 08:04 AM, the Registered Nurse Unit Manager, RN #75 confirmed she was unable to find a PT test for 12/10/18. | 2020-09-01 |