cms_WV: 3812
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3812 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 309 | G | 1 | 0 | 0AC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon observation, staff interview, and clinical record review, the facility failed to manage pain for one (1) of three (3) residents observed for pressure ulcer dressing changes. A staff member reported the resident cried out when her right foot was touched. Without assessing the resident for pain or premedicating her for pain, a nurse proceeded to provide wound care. During the nineteen (19) minutes the nurse provided care to the wounds, the resident cried out, pulled away, clutched her fists, and grimaced. Although the nurse providing the treatment had told the nurse administering medications she would stop the treatments and let her know if the resident needed something for pain, she did not stop until the care was completed. This resulted in a determination of physical harm and mental anguish for Resident #21. Facility census: 97. Findings include: a) Resident #21 Clinical record review revealed Resident #21 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment with an assessment reference date of 04/06/17 indicated Resident #21 had short-term and long-term memory problems and was severely impaired in decision-making. The resident required extensive one-person assistance with toileting, personal hygiene, dressing, and bathing and the extensive assistance of 2 persons for bed mobility. This incontinent resident had an unstageable pressure ulcer on her coccyx measuring 7 by 5 centimeters (cm) and a suspected deep tissue injury (SDTI) to right heel. On 04/19/17 at 10:10 a.m., Nurse Aide (NA) #39 came to nurses' station and reported to Licensed Practical Nurse (LPN) #69 and Unit Manager (UM) LPN #60 that Resident #21 was crying in pain, .whenever I touched her right foot. I think she needs something for pain. LPN #69 stated, while standing by the medication cart, I need to see if she needs Tylenol before you do the dressing change. UM #60 stated, I will check before I start, if she complains of pain, I will stop and do it later. On 04/19/17 at 10:12 a.m., UM #60 entered Resident #21's room to perform the resident's wound treatment. UM #60 touched Resident #21's right heel to apply Sureprep to the SDTI. Resident #21 closed her eyes, made a facial grimace as though in pain, open her mouth, cried out, pulled her arms to her chest, and clenched her fists. She shook her arms. UM #60 continued the treatment stating to resident, It is alright. UM #60 kept talking to resident about her family members, but continued with the treatment. UM #60 then performed the wound treatment to the unstageable coccyx wound. Resident #21 continued with facial grimacing and moaning. UM #60 then turned Resident #21 from side to side to change incontinence pad. Resident #21 cried out, grabbed at UM #60's ID badge, and pulled the badge with her closed fists. UM #60 completed the procedure at 10:30 a.m. and said to the resident, We will bring you some Tylenol now. At 10:35 a.m., UM #60 reported to LPN #69 that Resident #21 had some intermittent pain during the dressing change and, You can check to see if she needs some Tylenol. During an interview on 04/19/17 at 10:35 a.m., UM #60 stated Resident #21 does not like to be touched and that she would cry out. She stated it was difficult to determine when the resident was having pain. UM #60 she did not identify the resident's behaviors as signifying any possible pain. UM #60 stated she guessed should have just let the LPN premedicate the resident for pain and do the dressing change later. When observed on 04/19/17 at 12:00 p.m., Resident #21 was lying in bed on her left side. Her eyes were open, she exhibited no facial grimacing, and was not crying out. Her hands were no longer clenched, but were open and relaxed. During an interview on 04/20/17 at 9:30 am, the Administrator stated UM #60's behavior during Resident #21's dressing change did not meet facility standards and was unacceptable staff behavior. The administrator stated she could provide no explanation for the staff member's behavior. | 2020-08-01 |