cms_WV: 7624
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7624 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 428 | D | 0 | 1 | 0BYS11 | Based on medical record review, review of facility policy, and staff interview, the pharmacist failed to identify the lack of monitoring of a Lanoxin (digoxin) level, and failed to identify the use of an antipsychotic without monitoring. Two (2) of ten (10) Stage II sample residents were affected. Resident identifiers: #98 and #31. Facility census: 65. Findings include: a) Resident #98 Review of the order summary report, on 03/11/13 at 12:29 p.m., revealed Resident #98 was receiving Lanoxin (Digoxin) 0.125 mg by mouth one time a day for atrial fibrillation. The medication was ordered 12/24/12 and started on 12/25/12. Review of the pharmacist's medication regimen review, on 03/11/13 at 1:04 p.m., revealed no irregularities for 12/7/12, 1/30/13, or 2/21/13. On 03/11/13 at 2:15 p.m., record review found no lab order from the physician for a Lanoxin (digoxin) level to be collected to ensure the correct dosage of Lanoxin was being administered to Resident #98. During an interview, on 03/11/13 at 2:40 p.m., with Employee# 65, the director of nursing (DON), was asked whether the pharmacist's report included any irregularities regarding a Lanoxin (digoxin) level needing to be done for Resident #98. She confirmed no irregularities were reported and that no digoxin level was ever collected. Employee #65 stated she would notify the physician and obtain an order that day to collect a digoxin level. b) Resident #31 Medical record review found this resident began receiving Risperdal 0.5 mg. by mouth two (2) times a day for aggressive behaviors on 07/19/11. The resident was currently receiving Risperdal 0.25 mg. by mouth two (2) times a day. Review of the facility policy entitled, Behavior Monitoring, revised on 12/15/08 found, .Initiate the use of a behavior monitoring form (refer to Pharmacy Services Policies and Procedures Pharmacy Standard Forms policy). During an interview with the director of nursing (DON), Employee #65, at 12:48 p.m. on 03/11/13, she verified she would have expected the staff to complete a behavior monitoring sheet for the antipsychotic medication, Risperdal. She reviewed the medical record and stated a behavior monitoring sheet had not been completed since August 2012. The DON further verified the behavior monitoring sheet instructions directed the nursing staff to document the targeted behaviors for the use of the medication and the side effects of the medication. Nursing staff were to initial daily and document any behavior that occurred and any side effects the resident might have exhibited. The DON was unable to provide any documentation the facility was monitoring the resident's behaviors daily and monitoring for side effects of the medication. Review of the pharmacy monthly drug regimen reviews found the pharmacist had completed monthly reviews and was not aware, or did not identify, the facility had not been using the monthly psychoactive medication flow record, as directed by the facility's policy, to record the residents targeted behaviors or the side effects of the antipsychotic medication, Risperdal. The DON was interviewed on 03/11/13 at 12:48 p.m. She was unable to provide evidence the pharmacist had reported the irregularities to the attending physician or the director of nursing. | 2017-03-01 |