cms_WV: 61
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 61 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 602 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the resident's medications were not diverted to an unlicensed person for administration. A nurse gave [MEDICATION NAME] to a van driver to give to a resident while out of facility for an appointment. This is true for one (1) of two (2) complaint/concerns reviewed. Resident identifier: #239. Facility census: 140. a) Resident #239 Review of a complaint/concern with a date of 02/14/19 revealed a statement by registered nurse (RN) #94, explaining both she and the night nurse signed out, the pain medication, and placed the medication in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. The dosage is not revealed in the note. A grievance investigation form completed by risk manager RN #136 reveals, Resident left for at 7:15 AM for an appointment and medication was given to the van driver. According to Resident #239 she was given the medication, by the van driver, at approximately 8:30 AM. Resident #239's (MONTH) 2019 Medication Administration Record [REDACTED]. A new order with a start date of 02/13/19 is to give [MEDICATION NAME] 15 mg every four (4) hours as needed for pain. The first dose of this order was given on 02/13/19 at 7:54 PM. On 02/14/19 the MAR indicated [REDACTED]. Review of documentation concerning this matter found. 1. Van driver #63 was given the mediation by RN #94 who instructed the van driver to give to the resident at 12:00 PM. 2. A note written by the director of nursing reveals she spoke to van driver #63, who stated RN #94 gave him medication in a bag with instructions to give the medication to Resident #239 at 12:00 PM. This documentation is not signed by van driver #63. It is signed by the DON with a date of 02/15/19. 3. A note written by SS #111 in which Resident #239 stated she did not feel like it was not right for the van driver to give her [MEDICATION NAME]. 4. A note written by RN #136, with a date of 02/14/19 reveals, Van driver was given [MEDICATION NAME] tab to hand to this resident. He did not administer the med. Upon review of MARS, only dose documented was at 1 am on 2/14. Nursing supervisor said she was given [MEDICATION NAME] again around 4:35 am, but this dose was not documented on her MARS. Resident left for appointment @ 7:15 am. Med sent to appointment was given per resident from the van driver approximately at 8:30 am. Not documented on MARS upon return to facility same day. Appointment at 9 am. Resident returned around 11:15 am. Information given to Dir of Nurs to investigate by gathering witness statements and determining if resident right were violated. Email sent to Dir of Nurs on 2/25/as a follow up in regarding to resolving this grievance., On 07/31/19 at 4:00 PM the director of nursing expressed the incident was not reported to OHFLAC. A self-medication administration evaluation on 02/15/19, occurred after the incident. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. | 2020-09-01 |