cms_WV: 341
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 341 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 835 | D | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, observation, family interview, and resident interview the facility failed to ensure effective oversight and management of its operations. This failure resulted in deficient practices in the following areas: Notification of changes, nursing services, quality of care, and freedom from neglect. Resident #20 had a vagal nerve stimulator device used to control [MEDICAL CONDITION]. The facility staff were not trained on how to use this device. Some of the nursing staff assigned to care for the resident did not know the resident had the device. Resident #7 had experienced hallucinations and the staff did not acknowledge the resident's mental health issues in order to provide treatment for [REDACTED].#5 had experienced a stage IV pressure. The resident was dependent for turning and repositioning. Staff were not providing turning and repositioning every two (2) hours as indicated in the care plan. Staff did not timely assess and monitor Resident #2 at for changes in condition. On 10/10/18, at 2:35 PM, after consultation with the state agency a determination of immediate jeopardy was made. The facility failed to ensure that emergency medication was provided to a Resident #3 in accordance with physician's orders [REDACTED]. After the receipt of an acceptable plan of correction and implementation of the plan of correction (P[NAME]), the immediate jeopardy was abated on 10/10/18, at 8:44 PM. The facility implemented in-services for direct care staff regarding [MEDICAL CONDITION] care. Resident #3's physician was notified and orders for Intramuscular (IM) [MEDICATION NAME] was obtained. IM [MEDICATION NAME] was available in the emergency cart. Resident identifiers: #2, #7, #3, #5, and #20. Facility census: 83. Findings included: a) Resident #7 Resident #7 expressed he was having hallucinations when he was interviewed on 10/09/18 at 9:58 AM. He stated staff did not listen to him when he had expressed this concern many times. A review of the medical record on 10/10/18 at 10:00 AM revealed Resident #7 was taking an antidepressant medications. One of the interventions listed was to monitor adverse reactions that could be a side effect of the antidepressant medications. Discussion with Administrator Designee (AD) #51 at 10:35 a.m on 10/10/18 revealed AD #51 was not aware of the resident having hallucinations. AD #51 said he would be sccheduled to be seen by the physician on a visit next week. A review of a nursing summary report dated 10/01/18 did not show that halluciantions had been identified as a concern to monitor. Review of the care plan, on 10/10//18 and 10/11/18 at 9:30 a m., did not show that hallucination had been identifed as an actual problem which needed to be monitored and treated due to being a potential side effects from the antidepressant. b) Resident #3 A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/10/2018, at 8:50 AM, revealed the [MEDICATION NAME] gel had not been signed as given on the MAR for 09/29/18, when the prolonged [MEDICAL CONDITION] for 19 minutes occurred nor had it been signed for in the controlled medication notebook. Interviews with two (2) nursing staff, Licensed Practical Nurse (LPN) #105 and LPN #55, at this time, verified the medication was not documented on the MAR and was not signed out. In addition, Resident #3 did not have a sign out sheet for staff to document doses taken out of the locked box when required to treat the resident. Observation of the locked medication box revealed the cart did not contain any dose of the [MEDICATION NAME] gel ([MEDICATION NAME]) available to administer for Resident #3. Observations of the Automated Dispensing Unit, on 10/10/2018, at 8:50 AM, verified the [MEDICATION NAME] gel was not available. LPN #55 attempted to request the [MEDICATION NAME] gel for Resident #3 from the pharmacy, using the computer, after verifying the [MEDICATION NAME] gel was not available in the facility, but the request did not go through. The nurse responded, it must already have been re-ordered. It was then stated, by LPN #55, the [MEDICATION NAME] gel may have been locked up in the Director of Nursing's office. An interview, on 10/10/18, at 09:25 AM, with the Administrator Designee, verified the [MEDICATION NAME] is not in the building. An interview with the (name) Pharmacy, on 10/10/18, at 11:20 AM, verified the [MEDICATION NAME] gel had been ordered, on 12/22/16 and 06/14/2017. Further interview with the (name) Pharmacy, revealed the pharmacy had sent a request on 12/07/17 with additional follow-up requests on 12/08/17 and 12/12/17 to obtain a new physicians order with written script. To date, the facility had not sent the request for a current order and script to the pharmacy. On 10/10/18, at 2:35 PM, after consultation with the state agency a determination of immediate jeopardy was identified. The facility failed to ensure that emergency medication ([MEDICATION NAME] Gel) was provided to Resident #3 in accordance with physician's orders [REDACTED]. After the receipt of an acceptable plan of correction and implementation of the plan of correction (P[NAME]), the immediate jeopardy was abated on 10/10/18, at 8:44 PM. The facility implemented in services for direct care staff regarding [MEDICAL CONDITION] care. Resident #3's physician was notified and orders for Intramuscular (IM) [MEDICATION NAME] was obtained. IM [MEDICATION NAME] was available in the Emergency cart. On 10/11/18, at 11:55 AM, the Administrator Designee and RN#150 brought a prescription container of [MEDICATION NAME] gel to the surveyor. The Administrator Designee, stated it was not where the Director of Nursing (DoN) had told her to look but after the DoN thought about it, she had us to break the lock to get it. The [MEDICATION NAME] gel produced by the Administrator Designee and RN#150 had an original date of 06/14/17 with instructions to discard After 06/15/18. Both the Administrator Designee and RN #150 verified there was no current medication available in the facility to be used in case Resident #3 sustained a [MEDICAL CONDITION] greater than 5 minutes requiring medication to be administered. Further interviews, on 10/16/18, at 10:35 AM with RN#110 verified, meds are pulled based on discard date and RN#106 added, only meds to be destroyed are in the nurse's office (DoN) and that is where the outdated [MEDICATION NAME] was found. Further review of the medical record revealed Resident #3 had documentation of a [MEDICAL CONDITION] occurring on 08/17/18. There was no timed event for the duration of the [MEDICAL CONDITION]. The facility failed to provide [MEDICAL CONDITION] care that documented: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity as noted in Resident #3s care plan. Both [MEDICAL CONDITION] occurred during the time there was not a current prescription of the [MEDICATION NAME] gel available for the Resident and when the [MEDICATION NAME] Gel had not been available. The current physician's orders [REDACTED].) A review of the laboratory section of the medical record revealed no documented results for the [MEDICATION NAME] level ordered for (MONTH) (YEAR). An interview, on 10/15/18, at 2:30 PM with LPN #7, revealed no results were received and placed on the medical record. Upon further investigation, LPN #7 stated the lab had not been drawn according to the laboratory book. Additionally, the repeat Ammonia level ordered 08/20/18 was also not done. Review of the available labs, revealed Resident #3 had previously had higher levels than normal of [MEDICATION NAME]/[MEDICATION NAME] Acid at level 110 (normal range indicated 50-100 MCG/ML) {microgram/ milliliter} and Ammonia levels at level 40 (normal range indicated as 9.0-33.0 UMOL/L) {micromole per liter}. c) Resident #5 Notification of changes An interview, with Resident #5's Medical Power of Attorney (MPOA), on 10/14/18 at 6:00 PM, revealed Resident #5 had a (computed tompography (CT) scan. The MPOA said the facility did not inform him of the results from the CT scan. A progress note dated 07/30/18 stated, X-ray of right lower extremity reports [MEDICAL CONDITION] changes but could not rule out fracture of tibia. Discussed with FNP 'family nurse practicioner' and MPOA 'medical power of attorney.' New orders given for CT w/o (without) contrast of right lower extremity on 8/3/18 at (name of local hospital). MPOA (medical power of attorney) aware. A progress note dated 08/3/18 stated, Resident OOF 'out of facility' for CT scan via (name of ambulance company) per stretcher with 2 attendants. Further review of progress notes did not reveal any evidence indicating the MPOA was informed of the results of the CT. The CT scan report dated 08/03/18 did have hand written notes showing the family nurse practicioner was notified and that there was a new order for an orthopedic consult. However, there was no note to reflect the MPOA was notfieid of the CT results. On 10/15/18 at 11:38 AM Licensed Practical Nurse (LPN) #72 and Scheduler #16 looked through the resident's thinned medical record and located the results of the CT. There was no evidence the facility had informed the MPOA of the results. LPN #72 and Scheduler #16 confirmed the facility had no evidence to support they had informed Resident #5's MPOA of the results from the CT. A review of the facility's survey history revealed a complaint survey completed on 08/17/18 resulted in a deficient practice at F580 (notification of changes). Turning and Repositioning A review of Resident #5's treatment sheet revealed an order to turn and reposition the resident every two (2) hours due to increased risk of skin breakdown. Care plan review revealed Resident #5 had been treated for [REDACTED]. The care plan reflected the resident was incontinent of bowel and bladder and moved around in bed by sliding. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was totally dependent for bed mobility. Multiple observations on 10/10/18 between (9:00 AM and 1:00 PM) revealed Resident #5 was positioned with pressure off his right side. An interview with Nurse Aide (NA) #50 at 1:00 PM on 10/10/18 revealed the nursing staff were supposed to turn/reposition Resident #5 every two (2) hours but sometimes they were not able to do this due to staffing issues. Observations of Resident #5 on 10/10/18 at 1:48 PM revealed Resident #5 was positioned with pressure off his left side. Continued observations between 1:48 PM and 6:00 PM revealed the resident in the same position with pressure off his left side. On 10/10/18 at 6:06 PM during an interview with Registered Nurse (RN) #34 the RN said she would fix that when she was told the resident had been on the right side with pressure off the left side for the multiple observations between 1:48 PM and 6:00 PM. A review of the treatment record for (MONTH) (YEAR) revealed an order dated 07/10/18. The order indicated the resident would be turned every (two) hours, every shift due to an increased risk of skin breakdown. On 10/02/18 there was no documenation showing the resident had been turned on 7:00 AM - 7:00 PM shift. On 10/03/18 there was no documentation showing the resident had been turned every two (2) hours on 7:00 PM -7:00 AM shift. On 10/05/18 there was no documentation the resident had been turned during 7:00 AM -7:00 PM shift. On 10/06/18 there was no documentation the resident had been turned during 7:00 PM -7:00 AM shift. On 10/07/18 there was no documentation to show the resident had been turned during 7:00 PM-7:00 AM shift. On 10/09/18 there was no documentation to reflect the resident was turned during 7:00 AM-7:00 PM or 7:00 PM-7:00 AM. On 10/13/18 there was no documenation to show the resident had been turned during 7:00 PM-7:00 AM shift. On 10/14/18 there was no documenation the resident had been turned during 7:00 AM-7:00 PM shift. The resident's care plan reflected a focus area related to the resident's pressure ulcer to the right and left coccyx. The care plan indicated the resident was at risk for further skin breakdown related to imobility, refusal to turn and reposition, incontineince of bowel and bladder. Staff interview and record review as well as observations did not reflect the resident's refusal to be turned/repositioned. During a family interview, on 10/14/18 at 6:00 PM, Resident #5's family member said the resident had experienced a terrible pressure ulcer while at the facility. An interview with wound care RN #31 on 10/10/18 at 10:47 AM revealed Resident #5's wound was on the coccyx and had originated in (MONTH) (YEAR). The resident was on a wound VAC (vacuum assisted closure) for about eight (8) months. d) Resident #20 Review of records, on 10/10/18 at 10:15 AM, revealed some of Resident#20's [DIAGNOSES REDACTED]. Review of records revealed the resident had a vagal stimulator to be used during [MEDICAL CONDITION] activity. Vagal refers to the vagus nerve the longest nerve in the autonomic nervous system in the human body, which controls functions of the body that are not under voluntary control (such as heart rate and breathing). According to the [MEDICAL CONDITION] Foundation, Vagus nerve stimulation (VNS) prevents [MEDICAL CONDITION] by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. It is sometimes referred to as a pacemaker for the brain. A stimulator device is implanted under the skin in the chest. A wire from the device is wound around the vagus nerve in the neck. If a person is aware of when a [MEDICAL CONDITION] happens, they can swipe a magnet over the generator in the left chest area to send an extra burst of stimulation to the brain. For some people this may help stop [MEDICAL CONDITION]. A magnet is used to activate or deactivate the device. Review of Resident#20's care plan, on 10/10/18 at 10:15 AM, revealed a focus area of impaired Neurological status related to [MEDICAL CONDITION] disorder. Interventions included Give medications as ordered. Observe/document for effectiveness and side effects. Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No shortwave diathermy. The same intervention related to [MEDICAL CONDITION] activity concerning the vagal stimulator is under the focus of risk for falls. The intervention, Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No short-wave Diathermy. Date Initiated: 06/15/17. Review of records for Resident#20, on 10/10/18 at 2:00 PM, revealed an order for [REDACTED]. Review of the medicine administration record (MAR) revealed no [MEDICATION NAME] was given in the month of (MONTH) or (MONTH) (YEAR). The MAR showed in the month of (MONTH) one (1) dose was given on 08/27/18, indicating [MEDICAL CONDITION] activity had occurred. No details concerning the [MEDICAL CONDITION] activity occurring on 08/27/18 was found in the record; no description on how long the [MEDICAL CONDITION] lasted, or if the vagal stimulator was used, or what interventions or precautions were used other than the ordered medication. On 10/10/18 at 2:40 PM, interview with Registered Nurse (RN#105) assigned to care for the resident on 10/10/18, revealed RN#105 was not aware the resident had a vagal stimulator or what a vagal stimulator even was. RN#105 said this was her first day at the facility, that she was from a sister facility and did not know the residents. This surveyor suggested that perhaps another nursing staff that regularly worked at the facility and who was familiar with the resident, show this surveyor and the assigned RN#105 responsible for the care of Resident#20, the resident's vagal stimulator and the appropriate way to use it. Licensed Practical Nurse (LPN#72) showed this surveyor and RN#105 the procedure to use the vagal stimulator if the resident had a [MEDICAL CONDITION]. LPN#72 felt the resident's upper left chest and showed RN#105 the outline of the implanted vagal stimulator, then LPN#72 showed RN#105 the magnet hanging on the back of the resident's wheel chair that is used to operate the vagal stimulator. LPN#72 said there was also a magnet on the cart. LPN#72 said, the resident has been at the facility for ten (10) years and if he is having a [MEDICAL CONDITION], you swipe the magnet over the implanted vagal stimulator one (1) time, and only one (1) time. RN#105 said she had never came across one of those (vagal stimulator) before in her nursing career (RN#105 said she had been a RN since (MONTH) (YEAR), but a LPN for several years). On 10/10/18 at 5:45 PM, review of orders revealed an order dated 03/30/17, If resident has [MEDICAL CONDITION] activity last greater than 3 minutes, then RN to swipe magnet once over VNS Generator. If needed, can repeat after 5 minutes. Avoid swiping magnet immediately after single swipe. Notify physician and RP (representative) of use. Another order dated 3/31/2017 revealed, Device: Keep vagal Stimulator (used during [MEDICAL CONDITION] activity) in plain sight and handy at all times. Use vagal stimulator if he has more than one [MEDICAL CONDITION] in a row by rubbing magnet on left upper chest. No short-wave diathermy, microwave diathermy, therapeutic ultrasound diathermy. Every shift for [MEDICAL CONDITION] On 10/10/18 at 3:37PM, interview with RN#44 Staff Development, revealed when asked for records on all training given to staff concerning a vagal stimulator. RN#44 said, We don't have anyone in the building with a vagal stimulator. RN#44 said she has not done any training on vagal stimulators since she has had the job since the last part of (MONTH) (YEAR). The Staff Development RN#44 said she would look at previous records, prior to her having the position, to see if there ever was any training given concerning [MEDICAL CONDITION] or vagal stimulators. Interview with RN#44 Staff Development, on 10/10/18 at 4:17 PM after RN#44's review of training back through (YEAR), revealed no training on [MEDICAL CONDITION] or vagal stimulators. When asked again if anyone in the facility had a vagal stimulator, RN#44 replied, No one. This surveyor informed RN#44 that Resident#20 had a vagal stimulator. RN#44 left the room and came back a little while later and said, she was the only one that was not aware the resident had a vagal stimulator, that she had spoken to staff and everyone else knew about it and how to use it. When RN#44 was asked what model vagal stimulator the resident had, and how long he had had it, she was unable to say, but said she would try to find out. At the time of exit the facility had not given this surveyor the information on the model of the vagal stimulator or how long Resident #20 had it. On 10/10/18 at 7:35 PM, interview with LPN#47, evening shift nurse assigned to the resident revealed the LPN was not aware Resident #20 had a vagal stimulator or what a vagal stimulator was. When asked what the nurse would do if the resident had a [MEDICAL CONDITION] LPN#47said she would give him his PRN (as needed) medicine for [MEDICAL CONDITION]. When asked what the care plan intervention meant by Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. The LPN did not know, and said she had never seen any device bedside, and was unable to describe what a vagal stimulator was. An interview with Resident Care Specialist, also known as a Nurse Aide (NA) NA#35, on 10/10/18 at 7:40 PM, revealed NA#35 considered the Resident#20 total care. NA#35 said the resident needed a lot of care and he did have [MEDICAL CONDITION]. Upon inspection of the resident's wheel chair with NA#35, this surveyor pointed to the magnet attached to the back of the wheel chair and asked NA#35 what it was. NA#35 replied it was a wheel chair alarm, that a lot of residents had them so that staff would know when they stood up out of their wheel chairs. e) Resident #2 admitted originally on 05/19/18 status [REDACTED]. Resident had capacity. resident had a history of [REDACTED]. Review of records, on 10/09/18 at 11:15 AM, revealed a quarterly minimum data set (MDS) with an assessment reference date (ARD) 8/22/18. The resident had adequate hearing and vision, clear speech, can make self-understood and understands. Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 15 indicating the resident was cognitively intact with no impairment. The resident needed extensive assistance with activities of daily living (ADLs), except supervision with meals and is totally dependent for bathing. Pertinent [DIAGNOSES REDACTED]. On 10/09/18 at 1:05 PM review of record revealed a late entry situation background assessment recommendation (SBAR) Change in Status dated 09/22/18 at 4:40 PM. Review of SBAR Summary revealed documented vitals signs (blood pressure, temperature, pulse, and respirations) were taken on 09/19/18. The oxygen saturation noted was taken 09/18/18. Nurses note stated, What I think is going on with the resident is: has received first Cemo for metastisis of CA ([MEDICAL CONDITIONS] that has spread) had recently fracture to left arm while being turned and upon assessment her left elbow was very warm to touch Temp (temperature) -99.1. Additional Nursing Notes as applicable: Rp (representative) in facility and stated to send her mother to (name of specific hospital) ER (emergency room ) because that is where [MEDICAL CONDITION] doctors are. The hospital requested by family was not the nearest hospital to the facility. The family had to request resident be sent for evaluation. When reviewing the SBAR summary and SBAR no vital signs (VS) were recorded at the time the resident was having a change of condition, accept in a nurse's note a recorded temperature taken one time. The District Director of Clinical Services said the system pulls the last recorded VS into a note when no new VS are entered. Review of the SBAR dated the day Resident #2 was sent to the ED, 09/22/18, showed VS from 09/19/18, and oxygen saturation noted was taken 09/18/18. There were no recorded current VS reflecting the resident's actual status at the time of the change in condition. The instructions included on the SBAR were 1. Evaluate the resident, 2. Check vital signs, 3. Review record, 4. Review and interact care path or acute change in condition file card, and 5. Have relevant information available and reporting. The SBAR noted the situation is a change in condition noted as confusion with change in vials (written as typed) starting on 09/22/18. Stayed the same since change started with no change in symptoms. This condition, symptom, or sign has not occurred before. On the SBAR section 'Other relevant information', it was noted had family in from out of town all morning was laughing and taking pictures. Under section 'B' of the form under number three (3) instructions say (Be sure this is the most current set of vital signs that goes with your evaluation of the resident) The vital signs recorded on the form was actually taken on 09/19/18, the change in condition occurred on 09/22/18. The change in the resident's condition included increased confusion and slurred speech. The RN assessment revealed I think the problem may be has received first Cemo for metastisis (typed as written) of CA ([MEDICAL CONDITIONS] that has spread) had recently fracture to left arm while being turned and upon assessment her left elbow was very warm to touch Temp (temperature) -99.1. Nursing Notes for additional information on change of condition: Rp (representative) in facility and stated to send her mother to (name of specific hospital) ER (emergency room ) because that is where [MEDICAL CONDITION] doctors are. The physician was notified on 09/22/18 at 12:15 PM. Review of Hospital Emergency Department documentation dated 09/22/18, revealed at the time of the initial examination the resident was only alert to self, was hypotensive, and had elbow pain and swelling. She was treated for [REDACTED]. A chest x-ray was concerning for pneumonia. She did respond to IV fluid hydration and was no longer hypotensive. The resident required hospitalization for IV antibiotics. The resident's blood pressure was significantly lower than usual and she was hypotensive with a systolic of 70's. According to the family this afternoon she began having decreased alertness and became slightly altered. Throughout the evening she continued to become more altered and less responsive. The family noticed the residents left elbow was significantly more swollen and tender. (The resident had a [MEDICAL CONDITION] arm earlier in the month) On 10/16/18 at 12:55 PM, review of hospital discharge summary dated 09/29/18, revealed Resident #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The admitting [DIAGNOSES REDACTED]. Primary discharge [DIAGNOSES REDACTED]. Notations in the hospital records revealed, . The family notice that the wound appeared to be red and somewhat tender, and in addition notice that she had mental status changes today.and family asked that she be transferred for further evaluation The patient was initially hypotensive (low blood pressure) on arrival with elevated temperature, . On 10/16/18 at 3:11 PM, interview with Director of Legal Operations, the District Director of Clinical Services, Administrator, and interim Assistant Director of Nursing (ADON), revealed the SBAR was the documentation concerning what led up to sending Resident to the Emergency Department for evaluation. The Director of Legal Operations said the family was the ones that requested the resident be sent, and asked this surveyor if she had read the SBAR. This surveyor confirmed the SBAR dated 09/22/18 had been reviewed. The Director of Legal Operations said, The resident had been laughing earlier with the family, it was the family that requested the resident be sent. This surveyor said, Yes, the family did request the resident be sent, but don't you think nursing staff should have assessed and intervened without the family having to make the request, considering the condition the resident was in when she arrived at the hospital? No reply was made to the surveyor's question. After a pause, the Director of Legal Operations asked, Have you seen the hospital record? This surveyor replied, Yes, I have them. After another pause, the Director of Legal Operations said, I just wanted to know in case you wanted me to get them for you. | 2020-09-01 |