cms_WV: 6887
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6887 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2013-05-22 | 514 | B | 0 | 1 | M57P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medical record was accurate and complete for two (2) of twenty-two (22) sampled residents reviewed. Resident #3's medical record contained an altered physician's orders [REDACTED]. Resident #88's medication adminsitration records were unclear and inaccurate. Resident identifiers: #3 and #88. Facility census: 62. Findings include: a) Resident #3 A review of the resident's medical record, on 05/15/13, at 3:20 p.m., revealed physician's orders [REDACTED]. This medication was originally ordered to be given as needed (PRN) at bedtime. Further review of the medical record identified on the April 2013 physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR for February 2013, and March 2013, was altered with a line drawn through the at bedtime. An interview with Employee #27, a licensed practical nurse (LPN), at 3:22 p.m. on 05/15/13, revealed Resident #3 was receiving [MEDICATION NAME] ointment in both eyes as needed. She did not state the ointment was to only be given at bed time as needed as indicated on the original physician's orders [REDACTED].>Further interview with Employee #27, LPN, confirmed she did not know why the at bedtime was crossed out on the original physician's orders [REDACTED].#27 was unable to provide verification the physician had consented to this change. Interview with Employee #47, the assistant director of nursing (ADON) and Employee #21, the director of nursing (DON), on 05/15/13 at 3:32 p.m., further confirmed they did not why the at bedtime had been removed from the physician's orders [REDACTED].#21, the director of nursing, on the morning of 05/15/13, revealed she was unable to provide any evidence of a physician order [REDACTED]. She confirmed the resident received the medication whenever needed, not just at bedtime. b) Resident #88 Medication administration records were reviewed with the DON.[MEDICATION NAME](a medication to promote sleep) 5 mg po (by mouth) was noted as given at 11:20 a.m. on 11/14/13. Employee #29 (LPN), and the DON said the (entry) order was rewritten because the medication actually administered, was [MEDICATION NAME] 30 mg by mouth, which was noted above the (entry) order for the Ambien. Additionally, only a note at the top of the right side of the page indicated the [MEDICATION NAME] was rewritten. No indication was provided to indicate [MEDICATION NAME] was noted twice. Further review of the MAR indicated [REDACTED]. The entry on page 2 of 7 noted [MEDICATION NAME] 100 mcg patch, administer two (2) every three days, beginning on 03/11/13. This entry was not discontinued or removed from the MAR. The only indication of a second order was a note on the left side of the page, between the entry [MEDICATION NAME] order and the [MEDICATION NAME] order, which read see 1st page. The second entry order was noted for [MEDICATION NAME] 200 mcg/hr, to be applied every 72 hours, and was on a different change schedule than the initial entry. Employee #39 (RN) confirmed the medication in the medication cart was 100 mcg /hr. The physician's orders [REDACTED]. Employee #39 and the DON agreed the medication sheets were confusing. While reviewing the narcotic record, two (2) doses of Oxy IR liquid were noted as given. The DON said the 11:00 a.m. entry on 05/14/13, was incorrectly documented as liquid, and when actually a tablet was administered. The other dose of medication had not been entered into the narcotic log as given. The dose documented as given was not on the administration log, and the DON, confirmed it should have been. | 2017-11-01 |