cms_WV: 8622
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8622 | WAR MEMORIAL HOSP, D/P | 5.1e+151 | 1 HEALTHY WAY | BERKELEY SPRINGS | WV | 25411 | 2012-12-07 | 279 | E | 0 | 1 | L97I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a complete care plan addressing all identified problems by not including measurable goals and/or acceptable interventions for four (4) of fourteen (14) stage 2 sampled residents. Resident identifiers: Residents #9, #1, #2, and #7. Facility census 16. Findings include: a) Resident #9 Review of the medical record for Resident #9 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident had been receiving the medication [MEDICATION NAME] 1.25mg PO (by mouth) every evening for agitation since 10/25/2011. The medication was discontinued on 10/24/12, for a trial period at the request of the pharmacist who stated the following in a Psychoactive Pharmacy Drug Review: Olanazepin 1.25mg q hs (every night) with behavior noted by nursing notes as pleasant and cooperative. The medication was restarted on 11/14/12, when the resident was again exhibiting behaviors. Review of the current care plan revealed the facility had not adequately addressed the use of psychoactive medications. Although the medication was mentioned as an intervention associated with particular problems, the care plan did not describe problems that could arise from the use of the psychoactive medication, such as common side effects of the medication to which staff should be alerted. During an interview with the director of nurses (DON), at 4:00 p.m. on 12/06/12, she acknowledged, after reviewing the care plan, that it did not directly address psychoactive medications and problems that could arise from their use. b) Resident #1 Review of the medical record revealed Resident #1 was admitted to the facility, on 04/21/04, with a [DIAGNOSES REDACTED]. To treat those behaviors she was receiving [MEDICATION NAME] three (3) times daily. A review of her care plan revealed the following entry, dated 11/04/09, under Problems: Cognition, Behavior, Mood, & Psychoactive Drug Use: however, there was no measurable goal established for the use of psychoactive medications. The interventions included: Monitor for medication induced side effects and document behavior on Psychoactive Medication Record and Behavior Monitoring Record, and AIMS assessment every six (6) months, does exhibit extra pyramidal symptoms. The pharmacist reviewed the psychoactive medication use on 10/11/12, and suggested a change in the medication and/or dosage due to repetative tongue movements reported by the dietitian. The physician lowered the dosage of the [MEDICATION NAME] on 10/25/12, but no changes were made to the care plan. A measureable goal related to this was not established. During an interview with the DONat 4:00 p.m. on 12/06/12, she acknowledged, after reviewing the care plan, that although there was an entry for psychoactive medications in the problems, there had NOT been a measurable goal set. She stated she would talk to the pharmacist about doing so. c) Resident #6 On 12/06/12 at 2:30 p.m., a review, of the care plan for Resident #6, revealed there was no problem statement, goal, and/or interventions for [MEDICATION NAME] (a heart medication). d) Resident #2 During an interview, on 12/03/12 at 2:48 p.m., this resident stated she had a hard time chewing food because of her old teeth. A review of the medical record, on 12/06/12, revealed the resident had dental problems which might affect her nutrition intake. The care plan, dated 10/25/12, identified the resident's oral care, including dental visits, but lacked measurable goals to meet the resident's needs regarding her dental problems. During an interview, on 12/06/12 at 12:50 a.m. with licensed practical nurse (LPN) #19 she stated, staff assists resident with meal selection every week and the resident has never reported any difficulty with eating certain foods. Normal routine is to offer the resident another selection if she does not eat her meal. e) Resident #7 Review of the medical record revealed the resident is bedridden and dependent on staff for all activities of daily living (ADL) including social interactions and audiovisual stimulation. The Care Area Assessment (CAA) dated 06/18/12 identifies the resident's disease process and lists his choices as one on one visits with family, staff, and his dog; baseball games and catholic mass on television (TV); and music. Current care plan dated 12/14/12 lacks measurable goals and a time table related to activities for the resident. The care plan states staff will turn the television (TV) on for baseball games, sports and catholic mass, music is at the bedside and provided by the family, and the resident will receive one to one interactions with his family and/or the staff. The resident's daily participation records for August, September, October and November 2012, were reviewed by the social worker/activities director employee #23 during an interview on 12/05/12 at 9:20 a.m. She stated The nursing assistants haven't been filling them out. | 2016-05-01 |