cms_WV: 6601
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6601 | WAR MEMORIAL HOSPITAL | 5.1e+151 | 1 HEALTHY WAY | BERKELEY SPRINGS | WV | 25411 | 2013-10-17 | 279 | D | 0 | 1 | 9QWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop measurable goals for the care plan for one (1) of five (5) residents reviewed for unnecessary medications. The care plan identified Resident #2 had problematic behaviors and received antipsychotic medication daily. The care plan contained no measurable goals for which treatment and interventions were being provided related to the behaviors. Resident identifier: #2. Facility census: 15. Findings include: a) Resident #2 The medical record was reviewed for Resident #2. This resident was diagnosed with [REDACTED]. This was defined by specific behaviors as quantitatively (number of episodes) and objectively (such as biting biting, kicking, and scratching) documented by the facility which cause the resident to actually interfere with staff's ability to provide care. This resulted in the initiation of [MEDICATION NAME] (an antipsychotic medication) 25 milligrams (mg) daily. The [MEDICATION NAME] was begun on 09/28/13. Review of the care plan revealed this resident had repetitive obsessive behaviors. Numerous behaviors and interventions to treat the behaviors were identified on the care plan. However, the care plan contained no goals related to potential outcomes as the result of using the antipsychotic medication and the non-pharmacological interventions. On 10/16/13 at 2:10 p.m., an interview was completed with a licensed nurse, Employee #16. She said this resident had been sleeping during the day, especially when up to activities. She said she had noticed an improvement in the resident's activity participation and wakefulness over the past few weeks. An interview was conducted with the consultant administrator (Employee #48) on 10/16/13 at 2:15 p.m. She said this resident had been awake a good bit during the nights while displaying repetitive, obsessive behaviors. Numerous non-pharmacological interventions were tried by staff, to no avail. As a result of these obsessive, repetitive behaviors during the nights, she would then be too tired by day to take part in activities she once enjoyed. She said since beginning the [MEDICATION NAME] a few weeks ago, this resident had been getting more rest at night. Subsequently, the resident was more wakeful, active and able to socialize more by day. Employee #48 said she believed the resident's quality of life had improved since beginning the [MEDICATION NAME]. On 10/16/13 at 4:20 p.m., an interview was completed with the Director of Nursing (DON) and Employee #48. They acknowledged there were no measurable goals on the care plan related to the obsessive behaviors. They agreed there were no non-pharmacological interventions noted on the psychoactive medication monthly flow record, as there was not a place for that information. They said non-pharmacological interventions would be documented in the nurses' progress notes. However, since beginning the [MEDICATION NAME] on 09/28/13, there was no evidence staff were consistently trying non-pharmacological methods to address the behaviors. There were nineteen (19) shifts in October on the monthly flow record with documented obsessive behaviors. Review of nurses' progress notes for those shifts found no evidence of which, if any, non-pharmacological interventions may have been tried. Employee #48 said it was such a small facility, staff would just know what worked for the resident. She said staff should have documented the interventions, to receive credit for what they did. She added this issue would be addressed. | 2018-01-01 |