cms_WV: 4206
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4206 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2017-04-11 | 309 | K | 0 | 1 | XDKG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and physician interviews, the facility failed to ensure Resident #53 received [MEDICATION NAME], an anticoagulant (blood thinner) upon return from a stay at an acute care hospital. After initiating [MEDICATION NAME] therapy, the facility failed to ensure prompt notification of the resident's physician of the results of ordered [MEDICATION NAME]/International Ratio (PT/INR) laboratory (lab) tests. Additionally, on two (2) separate occasions, the physician gave orders to increase Resident #53's [MEDICATION NAME], but the facility failed to administer the increased dose until the next day despite the fact it was available in the emergency medication box. These significant medication errors placed Resident #53 at an immediate risk for serious harm and/or death, resulting in a determination of immediate jeopardy. Additionally, the discharge summary from the hospital included an appointment was scheduled with a cardiologist for 04/04/17. The resident, who had a recent [MEDICAL CONDITION] infarction, did not attend due to the facility's failure to arrange for transportation to and from the appointment. The Nursing Home Administrator (NHA) and the Director of Nursing (NHA) were notified of the immediate jeopardy at 3:05 p.m. on 04/06/16. The facility provided a plan of correction (P[NAME]) to the State agency at 4:13 p.m. on 04/06/17, which the State agency reviewed and accepted at 4:17 p.m. on 04/06/17. The State agency representatives onsite ascertained implementation of the P[NAME] and abated the immediacy at 4:50 p.m. on 04/06/17. This immediate jeopardy began on 03/21/17, when the facility failed to initiate [MEDICATION NAME] therapy. From 03/21/17, forward the facility continued to make errors in following resident's plan of care. After removal of the immediacy, deficient practices remained for Residents #76 and #79. The scope and severity was decreased from a K to D for the deficient practices that were no a part of the immediate jeopardy. For Resident #76, a scheduled appointment with the wound care center was not kept and Resident # 79 had non-pressure related wounds for which the facility failed to attempt to determine the cause of her wounds. These issues were found for three (3) of twenty-three (23) sampled residents. Resident identifiers: #53, #76, and #79. Facility census: 113. Findings include: a) Resident #53 1. A review of Resident #53's medical record at 12:00 p.m. on 04/05/17, found the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The discharge instructions included, but not limited to: -- [MEDICATION NAME] ([MEDICATION NAME]) two (2) milligrams (mg) by mouth daily at bedtime for treatment of [REDACTED]. -- A scheduled appointment with a Cardiologist on 04/04/17 at 10:20 a.m. for follow-up treatment of [REDACTED]. (Address and phone number included) -- The facility was to call for an appointment with a neurologist within six (6) weeks from date of discharge. (Address and phone number included) Review of Resident #53's Medication Administration Record [REDACTED]. The medication was started after the attending physician visited and ordered [MEDICATION NAME] 2 mg and a PT/INR on 03/23/17. During an interview at 11:15 a.m. on 04/06/17, when asked about the resident not receiving [MEDICATION NAME] after her readmission, the resident's attending physician stated she would not have discontinued the resident's [MEDICATION NAME] unless she had hematuria or some other bleeding condition. (The medical contained no evidence Resident #53 had these conditions). The physician further stated she did not recall if they told her the resident was started on [MEDICATION NAME] while in the hospital. She stated, I don't remember what they found I would have to look at her record. The facility did not obtain the PT/INR ordered on [DATE] until 03/27/17. The results of the PT/INR obtained at 5:00 a.m. on 03/27/17, were available for review by the facility by 1:00 p.m. on 03/27/17. Facility staff did not review or print the results of this PT/INR until 03/28/17. On 03/28/17, the facility reported the PT/INR result of 1.21 to the physician by telephone, at which time the physician increased the dose of [MEDICATION NAME] to 3 mg. However, the facility did not increase Resident #53's [MEDICATION NAME] dose until the evening of 03/29/17, despite the fact it was available in the emergency medication box. The facility obtained the repeat PT/INR 04/03/17 as ordered, but did not notify the physician of the PT/INR results obtained on 04/03/17, until 04/04/17 of the result of 1.39 (low). The physician then gave orders to increase the resident's [MEDICATION NAME] to 4 mg. She did not get the first dose of this increased dosage until 04/05/17, despite the fact it was available in the emergency medication box. An interview with the Director of Nursing (DON) on 04/06/17 at 11:25 a.m., found the facility had an emergency medication box that contained [MEDICATION NAME]. She confirmed Resident #53 did not receive the [MEDICATION NAME] as ordered. 2. The facility failed to arrange transportation for Resident #53 to and from her appointment with the cardiologist scheduled for 10:20 a.m. on 04/04/17. Therefore, the resident was not seen by the cardiologist after her recent [MEDICAL CONDITION] as directed by the discharge summary due to the facility's failure to make arrangements. An interview with the DON on 04/06/17 at 10:30 a.m., found the facility followed the hospital discharge summary when a resident was admitted /readmitted to the facility unless the attending physician specified differently. When the attending physician wished to provide a different medication and/or treatment, it was documented in the nurses' notes. She verified the physician wished to follow the orders as directed by the discharge summary. 3. These failures by the facility placed Resident #53 at an immediate risk for serious harm and/or death. This has resulted in a determination of immediate jeopardy. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified of the immediate jeopardy at 1:30 p.m. on 04/06/16. The facility provided a plan of correction (P[NAME]) to the State agency at 4:13 p.m. on 04/06/17, which the State agency reviewed and accepted at 4:17 p.m. on 04/06/17. The State agency representatives onsite, verified implementation of the P[NAME] and abated the immediacy at 4:50 p.m. on 04/06/17. This immediate jeopardy began on 03/21/17, when the facility first began to fail to provide appropriate medications and treatments as outlined in the discharge summary from an acute care hospital for treatment of [REDACTED]. From 03/21/17, forward the facility continued to make errors in following the identified resident's plan of care. After removal of the immediate jeopardy, deficient practices. not a part of the immediate jeopardy remained for Residents #76 and #79. The scope and severity was decreased from a K to D 4. The Facility's Plan of Correction contained: On 04/06/17 Medical Director and Director of Nursing implemented the following plan: -- The DON and LPN immediately evaluated the resident number 53. Vital signs were B/P (blood pressure) 108/58, SPO2 (oxygen saturation) 97% on 2L O2 (2 liters of oxygen), RR 20 (respiratory rate), Temp 98.6 (temperature), and Pulse 87. The resident assessment revealed resident without s/s of distress. No bleeding or new bruising noted to skin. Old ecchymosis areas in various shades were noted on her arm, abdomen, and around her right knee. The DON notified the physician of the resident condition and re-notified the physician of a PT/INR that was not obtained on 3/23/17 as ordered following a med error/lab error from a readmission on 3/21/17. The DON also re-reported the PT/INR values for the labs collected on 3/27/17 and 4/3/17 and the subsequent orders given by the physician. The physician was notified of a missed cardiology appointment scheduled for 4-4-17 and discussed previous discharge orders that required the resident to be re-evaluated within 6 weeks. Staff re-scheduled an appointment for the earliest available appointment on (MONTH) 28th (YEAR), which falls within the 6 week time period. The physician requested the resident be sent to the emergency room for further evaluation. During the emergency room evaluation, the physician will request a complete cardiac work up. Nursing staff present were immediately in-serviced and all other nurses will be in-serviced prior to their next scheduled shift by the DON or designee on [MEDICATION NAME] therapy, collecting labs, reporting lab findings, reporting [MEDICATION NAME] levels promptly, starting medications within a reasonable time following order, utilization of he ER box if medications are needed, ordering labs, making follow up appointments, and transcribing admission and readmission orders [REDACTED] -- The DON and nursing staff will review the medical records for all other resident's receiving [MEDICATION NAME]. All residents receiving [MEDICATION NAME] will be assessed by nursing staff and documentation will be provided in the medical record. All residents receiving [MEDICATION NAME] will be ordered a stat PT/INR to ensure therapeutic levels. Once the levels are received they will be reported promptly to the physician for orders as indicated. The DON and nursing staff will review the medical records of all admissions and re-admissions for (MONTH) of (YEAR) to ensure all admission/re-admission orders [REDACTED]. If the in house physician does not agree with an order, documentation and rationale for order not being completed will be documented in the medical record. -- Because this had the potential to effect all residents receiving [MEDICATION NAME], nursing staff present were immediately in-serviced and all other nurses will be in-serviced prior to their next scheduled shift by the DON or designee on [MEDICATION NAME] therapy, collecting labs, reporting lab findings, reporting [MEDICATION NAME] levels promptly, starting medications within a reasonable time following order, utilization of the ER box if medications are needed, ordering labs, making follow up appointments, and transcribing admission and readmission orders [REDACTED]. PT/INR levels will be recorded on a monitoring log for each resident on [MEDICATION NAME] and will be promptly reported for the physician. A re-admission/admission monitor will be instituted to ensure that all orders are properly transcribed into the facility system and ordered as directed by the physician. A [MEDICATION NAME] therapy monitoring for will be instituted and to ensure [MEDICATION NAME] levels are obtained as prescribed, results are called to the physician in a timely manner, and medications are started in a timely manner. -- The interdisciplinary team will review the aforementioned monitoring forms at the weekly team meeting for quality improvement x 8 weeks or until the committee determines satisfactory resolution has been achieved to ensure compliance. -- All nurses will be in-serviced prior to working their next shift. All resident charts will be reviewed by 4-14-17. c) After removal of the immediate jeopardy, deficient practices remained for Residents #76 and #79 at a scope and severity of D 1. Resident #76 Review of Resident #76s medical record on 04/10/17 at 9:45 a.m., revealed the resident had a Stage 4 pressure ulcer on right foot Symes amputation (an amputation through the ankle joint) site which occurred following an attempt to wear a prosthesis. An outside wound clinic treated and monitored the pressure ulcer. Review of consultation reports found an outside wound clinic saw and treated Resident #76' pressure ulcer on 03/13/17. This consult specified recommended treatments and a return appointment in three (3) weeks. The facility physician ordered an appointment for the resident to go to the wound clinic on 04/03/17. There was no evidence found in the resident's medical record to indicate the resident went to the wound clinic on the specified date, and if not, why the resident missed the appointment. An interview with the DON on 04/10/17 at 12:30 p.m., found the staff did not know why the appointment with the wound care clinic had been missed. She further confirmed the appointment had been rescheduled. c) Resident #79 At 8:06 a.m. on 04/04/17, observation of the resident found he had numerous areas of discoloration to both forearms and a band-aid on his right elbow. The areas were various shades of red and purple. Review of a monthly summary, dated 03/03/07, found the resident had no skin issues. Further review of the medical record found a nurse's note, dated 04/04/17, New orders received and noted to cleanse open ecchymotic area to right elbow with NNS (normal saline solution), Pat dry, apply [MEDICATION NAME] and cover with band aid daily and PRN (as needed), Left message for A second nurse's note, dated 04/03/17, New orders received and noted to discontinue tx (treatment) to right and left forearm areas resolved. At 1:42 p.m. on 04/05/17, Licensed Practical Nurse (LPN) #31, when asked if she had any information regarding the reddened areas on the resident's forearms and the skin tear, said she did not have an incident report for the skin tear. She said the reddened areas on the resident's forearms were ecchymotic areas due to the use of [MEDICATION NAME] (an anti-platelet). At 1:53 p.m. on 04/05/17, LPN #22 said the area to his elbow was just a scab the resident had picked at. The areas come and go where he just constantly picks, he is on [MEDICATION NAME]. Review of the current care plan found the use of [MEDICATION NAME] and the ecchymotic areas identified by the staff were not currently care planned. She stated, I did not care plan the use of [MEDICATION NAME]. On 04/03/17 at 9:27 a.m., Registered Nurse (RN) #38, the quality assurance coordinator, was asked if the facility had any information regarding the reddened areas to the resident's forearms and the recent skin tear to the resident's elbow. She had no additional information to offer. At 11:05 a.m. on 04/11/17, RN #4 said she had ordered elbow protectors, after surveyor intervention, for the resident because he hits his arms on things. On 04/11/17, at 11:06 a.m., the director of nursing (DON) said she would have expected staff to do an incident report to attempt to determine how the skin tear could have occurred. The DON was unable to provide any evidence to explain what had caused, or may have caused, the discolorations. Prior to the surveyor asking about the resident's skin condition, there was no documentation regarding the areas observed on the resident's forearms and the recent skin tear to the right elbow other than the 04/05/17 order for treatment for [REDACTED]. | 2020-02-01 |