| 7930 |
ANSTED CENTER |
515133 |
96 TYREE STREET |
ANSTED |
WV |
25812 |
2012-12-11 |
279 |
E |
0 |
1 |
K06L11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, family interview, and staff interview, the facility failed to develop a comprehensive care plan for five (5) of thirty-one (31) Stage 2 sample residents. The facility failed to develop a care plan related to the use of antidepressants, prevention of contractures, care of pressure ulcers, measurement of urinary output, nausea and vomiting, [MEDICAL CONDITION] reflux disease, and insulin usage. Resident identifiers: #61, #10, #26, #19, and #62. Facility census: 60. Findings include: a) Resident #61 Review of the medical record identified Resident #61 received the antidepressant [MEDICATION NAME] for a [DIAGNOSES REDACTED]. No interventions were in place for staff to follow related to the use of this medication. Additionally, no side effects were identified for staff awareness and observation. This information was confirmed with Employee #36, the director of nursing (DON), on 12/06/12 at 9:14 a.m. b) Resident #62 Medical record review found the resident had a Foley catheter for a [DIAGNOSES REDACTED]. Further review of the physician's orders [REDACTED]. Review of the resident's current care plan, dated 03/30/12, found a problem: Resident requires indwelling Foley catheter due to: stage 3/4 pressure ulcer and quadriparesis at risk for infection. The care plan failed to address measuring urinary output on each shift. The DON was interviewed on 12/06/12 at 10:00 a.m. She acknowledged the care plan did not address the physician's orders [REDACTED]. c) Resident #10 During a stage one interview, on 12/03/12 at 2:53 p.m., the nurse stated Resident #10 had a contracture of the left hand. She related the resident did not wear a splint, and did not receive range of motion services. An observation and interview was completed with Resident #10 on 12/04/12 at 2:18 p.m. Observation of the resident revealed a contracture of her left hand. She stated services were not performed to maintain range of motion. She stated her contracture was related to a stroke. Review of the medical record, on 12/05/12, revealed the care plan did not address the contracture of the resident's left hand. The minimum data set (MDS) was reviewed on 12/11/12 at 9:00 a.m. The assessment dated [DATE] indicated the resident had an impairment of one of her upper extremities. Section S of the comprehensive assessment, dated April 2012, indicated the resident had a contracture of the left hand. Employee #57, a certified nursing assistant and family member, was interviewed on 12/11/12 at 10:10 a.m. She stated the resident did not receive therapy for the contracture of her left hand. The resident was interviewed on 12/11/12 at 10:15 a.m. She was alert, verbal and coherent. She said her hand had been this way since my stroke. She again stated the staff did not provide range of motion, nor encourage her to perform range of motion on her left hand. Employee #35, a registered nurse care plan coordinator (RN CPC), was interviewed on 12/11/12 at approximately 3:00 p.m. She acknowledged the contracture was not addressed on the care plan. Employee #31, another RN CPC, was also interviewed on 12/11/12 at approximately 3:00 p.m. She stated the MDS identified the contracture of Resident #10's left hand on the April 2012 assessment. She indicated the contracture was not addressed because it did not pull to section V for care area assessment. Employee #31 agreed the contracture of the the resident's left hand was not addressed in the care plan. d) Resident #26 Medical record review, completed on 12/10/12, indicated Resident #26 received seventeen (17) units of [MEDICATION NAME] subcutaneously daily. Additionally, the resident received [MEDICATION NAME] R solution 100 units/ml subcutaneously with sliding scale coverage four (4) times daily. The care plan was was reviewed on 12/05/12 and again on 12/11/12. It did not identify clinically significant adverse effects related to [DIAGNOSES REDACTED] or [MEDICAL CONDITION] that facility staff should be prepared to recognize. physician's orders [REDACTED]. The care plan was reviewed on 12/06/12 and again on 12/11/12. It did not address nausea, vomiting or the use of [MEDICATION NAME]. A physicians order review, completed on 12/06/12, indicated Resident #26 was started on [MEDICATION NAME] 20 mg by mouth twice daily related to [MEDICAL CONDITION] reflux disease (GERD). Review of the care plan on 12/06/12 and again 12/11/12 revealed [MEDICAL CONDITION] the use of [MEDICATION NAME] was addressed. . e) Resident #19 On 12/10/12 at 11:51 a.m., a medical record review was conducted revealing Resident #19 had a treatment order for wound vac therapy (delivery of negative pressure to promote healing) for a pressure ulcer to the coccyx area. This treatment continued until the resident was discharged to the hospital on [DATE]. On 12/10/12, the most recent care plan for this resident was reviewed. It indicated the last revision by the facility was completed on 08/08/12. This care plan made no mention of the implementation of the wound vac treatment for [REDACTED]. During an interview, on 12/11/12 at 1:21 p.m., with the DON, she confirmed the care plan did not address the wound vac therapy as treatment for [REDACTED]. |
2016-12-01 |