cms_WV: 5442
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5442 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2015-07-09 | 278 | B | 0 | 1 | R3IE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0 (RAI Manual), and staff interview, the facility failed to ensure three (3) quarterly assessments and one (1) discharge return anticipated assessment, accurately reflected the residents' status for three (3) of sixteen (16) residents whose minimum data set (MDS) assessments were reviewed during Stage 2 of the survey. Resident #26 was inaccurately assessed as taking a hypnotic medication when she was not. Resident #34 was inaccurately assessed as taking a diuretic medication when she was not. Resident #68 had two (2) quarterly assessments which were not coded to reflect the [DIAGNOSES REDACTED]. Resident identifiers: #26, #34, and #68. Facility census: 109. Findings Include: a) Resident #26 A review of Resident #26's medical record at 9:30 a.m. on 07/08/15, revealed a discharge return anticipated minimum date set (MDS) assessment, with an assessment reference date (ARD) of 02/14/15. Item N0410 D. Hypnotic was coded with a six (6). This indicated Resident #26 received a Hypnotic medication six (6) of the seven (7) days during the look back period. Review of Resident #26's Medication Administration Records (MARs) for the month of (MONTH) (YEAR), found Resident #26 did not receive any hypnotic medications during the seven (7) day look back period. The instructions in the RAI Manual for coding Item N0410 are: Indicate the number of days the resident received the following medications during the last 7 (seven) days or since admission/entry or reentry if less than 7 (seven) days. Enter 0 (zero) if medication was not received by the resident during the last 7 (seven) days. An interview with Registered Nurse Assessment Coordinator (RNAC) #43 at 2:30 p.m. on 07/08/15, confirmed Resident #26 did not receive a hypnotic medication during the seven (7) day look back period. She stated, I must have counted the [MEDICATION NAME] because she receives it for [MEDICAL CONDITION]. RNAC #43 then confirmed that [MEDICATION NAME] was not a hypnotic and the MDS was inaccurately coded. b) Resident #34 A review of Resident #34's medical record at 2:06 p.m. on 07/08/15, found the quarterly MDS with an ARD of 11/26/14 coded with a 7 for item N0410 G. Diuretic. This indicated Resident #34 received a diuretic medication seven (7) of the seven (7) days during the look back period. Review of Resident #34's Medication Administration Records (MARs) for the month of (MONTH) 2014 found Resident #34 did not receive any diuretic medications during the seven (7) day look back period. The instructions for coding Item N0410 in the RAI Manual are: Indicate the number of days the resident received the following medications during the last 7 (seven) days or since admission/entry or reentry if less than 7 (seven) days. Enter 0 (zero) if medication was not received by the resident during the last 7 (seven) days. An interview with Director of Nursing (DON) #42 at 4:10 p.m. on 07/08/15, confirmed Resident #34 did not receive a diuretic medication during the seven (7) day look back period. She indicated they must have counted the resident's [MEDICATION NAME] (an antihypertensive) as a diuretic, but confirmed that was inaccurate and the MDS would need to be corrected. c) Resident #68 Review of the medical record on 07/07/15 at 1:30 p.m., found a physician's progress note dated 11/08/14, which addressed the resident's bladder obstruction and the need for an indwelling urinary catheter. According to the quarterly minimum data set (MDS), with and assessment reference date (ARD) of 02/15/15, this resident had an indwelling urinary catheter. Item I1650 was coded as not having a [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 05/08/15, found this resident continued to have an indwelling urinary catheter. Item I1650 again was not coded as the resident having a [DIAGNOSES REDACTED]. During an interview with an MDS coordinator, Registered Nurse #44, on 07/07/15 at 3:55 p.m., she said both the 02/15/15 and the 05/08/15 quarterly MDSs were incorrectly coded for Item I1650. She said the [DIAGNOSES REDACTED]. She said it would be coded correctly on the next MDS. | 2019-01-01 |