cms_WV: 4042
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4042 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 282 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow the comprehensive care plan for three (3) of five (5) residents reviewed for unnecessary medications. For Residents #34 and #49's the facility failed to implement their care plans directing to utilize nonpharmacological methods to treat behaviors prior to administering medications, and to assess the effectiveness of the as needed (PRN) antianxiety medication. The facility failed to implement Resident #10's care plan directing administration of insulins as ordered by the physician for the [DIAGNOSES REDACTED].#34, #49, and #10. Facility census: 61. Findings include: a) Resident #34 Review of the resident's medical record on 02/15/17 found [DIAGNOSES REDACTED]. The physician prescribed an antianxiety medication, [MEDICATION NAME] one (1) milligram (mg) every eight (8) hours as needed (PRN). The comprehensive care plan review revealed numerous nonpharmacological interventions such as offering a quiet environment, 1:1 (one person to one person), offer fluid/foods, toileting, conversing, activities, observe for pain, and calm approach, before administering the PRN [MEDICATION NAME]. The care plan also directed to monitor the effectiveness of the PRN medications. Review of the medical record found several instances this quarter where the care plan was not followed. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/07/16 at 8:00 p.m. The nurse progress notes provided no evidence of what, if any, nonpharmacological methods were attempted prior to administering the PRN medication. Also, the medical record was silent as to whether or not the medication was effective. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/11/16 at 9:00 p.m. for anxiety. Review of the medical record found no evidence of what if any nonpharmacological methods were attempted prior to giving the PRN medication. - Review of the medical record found a nurse administered a 1 mg dose of PRN [MEDICATION NAME] to this resident on 12/13/16 at 10:20 p.m. Review of the nurse progress notes found no evidence of what, if any, non-pharmacological methods were attempted prior to giving the PRN medication. - Review of the medical record found a administered a 1 mg [MEDICATION NAME] tablet to this resident on 12/16/16 at 9:45 p.m. due to aggression toward staff and hitting staff after she could not be redirected. The medical record was silent as to whether or not the medication was effective. - Review of the medical record found a nurse administered 1 mg of PRN [MEDICATION NAME] to this resident on 01/14/17 at 11:43 p.m. Review of the medical record found no evidence of what, if any, nonpharmacological methods were attempted prior to giving the PRN medication. On 02/16/17 at 8:45 a.m., the director of nursing provided what documentation she could find about the resident's behaviors when given [MEDICATION NAME], what nonpharmacological methods were tried prior to giving the [MEDICATION NAME], and assessment of the effectiveness of the PRN [MEDICATION NAME]. On 02/20/17 at 2:30 p.m., a brief discussion with the DON about the issues of not following the care plan to monitor the effectiveness of the PRN [MEDICATION NAME], not following the care plan to attempt nonpharmacological methods to address her behaviors prior to administering the [MEDICATION NAME], and not assessing the medication's effectiveness. There was no evidence staff used nonpharmacological methods prior to administering the PRN [MEDICATION NAME] on 12/07/16, 12/11/16, 12/13/16, and 01/14/17. There was no evidence as to whether the 12/07/16 and the 12/16/16 doses of [MEDICATION NAME] were effective. On 02/22/16 at 1:00 p.m., Registered Nurse #111 said she was unable to find any further evidence. During an interview on 02/28/17 at 3:00 p.m., the administrator acknowledged the resident's care plan was not always followed related to the [MEDICATION NAME] use. b) Resident #49 Medical record review on 02/15/17 found this resident had [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. The care plan directed to try nonpharmacological interventions for behaviors such as, but not limited to, activities, interact with her 1:1, exercise, offer food/fluids, and observe for pain. Review of the medical record found this resident received PRN [MEDICATION NAME] on two (2) occasions without evidence that nonpharmacological interventions were attempted prior to giving her PRN [MEDICATION NAME]. A nurse progress note dated 02/07/17 at 3:00 p.m. described the resident was agitated over a band playing music in the solarium. She cursed and talked loudly, so that she had to be removed due to her disruptions. The nurse administered the PRN [MEDICATION NAME] without any evidence of first attempting nonpharmacological methods to help the resident calm. On 02/08/17 at 3:00 p.m., the nurse administered a PRN dose of [MEDICATION NAME] 0.5 mg. for anxiety. Review of the progress note for that time found no description of the type of behaviors she exhibited. There was no evidence the nurse attempted any nonpharmacological methods prior to medicating the resident, nor did the nurse assess the effectiveness of the medication. On 02/20/17 at 2:15 p.m., Registered Nurse #111 printed nurse progress notes for (MONTH) (YEAR) for the two (2) doses of the PRN antianxiety medication. She agreed the nurses did not identify any nonpharmacological methods attempted prior to medicating the resident with the [MEDICATION NAME], and one (1) of the two (2) did not note the effectiveness. During a brief interview with the director of nursing (DON) on 02/20/17 at 2:30 p.m., she was informed of these findings and asked to provide any additional evidence available. No additional information was provided prior to exit. In an interview on 02/28/17 at 3:00 p.m., the administrator acknowledged that nursing staff did not always justify the use of the PRN [MEDICATION NAME]. c) Resident #10 Review of the resident's medical record on 02/21/17 at 1:17 p.m. revealed his [DIAGNOSES REDACTED]. He was ordered blood glucose monitoring twice a day, with scheduled [MEDICATION NAME]90 units to be administered in the morning and scheduled [MEDICATION NAME]80 units to be administered in the evening at bedtime. [MEDICATION NAME]10 units was scheduled to be administered in the morning before breakfast and [MEDICATION NAME]15 units scheduled to be administered in the afternoon before dinner. A pharmacy consultation report issued on 12/07/16 included, Records show on 11/29/16, 12/03/16, 12/04/16, and 12/05/16 no morning [MEDICATION NAME] given. Recommendation: Please educate nursing on importance of proper dosing and [MEDICATION NAME] doses should not be held. Rationale for Recommendation: Basal insulins, such as [MEDICATION NAME] do not affect blood glucose concentrations immediately after administration. The resident's care plan listed a problem of, Resident has Diabetes Mellitus. Potential for episodes of hypo/[MEDICAL CONDITION] (low/high blood sugar). The interventions included, Administer medication as order by MD (medical doctor). The resident's Diabetic Flow Sheet revealed: -- 11/29/16 at 0641 (6:41 a.m.) - blood glucose result of 117, with no morning scheduled [MEDICATION NAME]administered and no physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) - blood glucose result of 252 (high). -- 12/03/16 at 0600 (6:00 a.m.) - blood glucose result of 259 (high), with no morning scheduled [MEDICATION NAME]administered and no physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) - blood glucose result of 245 (high). -- 12/04/16 at 0641 (6:41 a.m.) - blood glucose result of 128, with no morning scheduled [MEDICATION NAME]administered and no physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) - blood glucose result of 243 (high). -- 12/05/16 at 0600 (6:00 a.m.) - blood glucose result of 69, with no morning scheduled [MEDICATION NAME]administered and no physician notification of the medication not given as ordered or of blood glucose level being below 70 as ordered. At 2145 (9:45 p.m.) - blood glucose result of 383 (high). The resident's care plan listed a problem of, Resident has Diabetes Mellitus. Potential for episodes of hypo/[MEDICAL CONDITION] (low/high blood sugar). The Interventions included, Administer medication as order by MD. After reviewing the pharmacy consultation report dated 112/07/16, Diabetic Flow Sheet dated 11/28/16 to 12/07/16 and the resident's care plan on 02/27/17 at 2:10 p.m., the Director of Nursing (DON) agreed the nurse(s) did not administer the scheduled morning insulin for Resident #10 as ordered by the physician. She also verified the nurse did not notify the physician on any of the days the morning insulin was not administered, because absolutely the physician should have been notified on each of those days. The DON stated, I don't know why the nurse held those doses and just glad that he (Resident #10) did not have any complications arising from the insulin being held because he certainly could have had some serious complications. No absolutely the care plan was not followed as far as administering medication as ordered. | 2020-02-01 |