cms_WV: 935
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 935 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 656 | D | 0 | 1 | 06KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to develop a care plan for a [MEDICAL TREATMENT] resident with interventions addressing complications related to [MEDICAL TREATMENT], pre and/or post [MEDICAL TREATMENT] assessments, blood pressure parameters, and post [MEDICAL TREATMENT] treatment care upon return to the facility from the [MEDICAL TREATMENT] center. This was true for one of one resident reviewed for [MEDICAL TREATMENT] services. This practice has the potential to affect a limited number of residents. Resident identifiers: R32 . Facility census: 75. Findings included: Review of records, on 05/14/19 at 09:39 AM, revealed Resident (R#32) brief interview for mental status (BIMS) score is fourteen (14) indicating resident is cognitively intact. The resident needs extensive to total assistance for activities of daily living. Some pertinent [DIAGNOSES REDACTED]. Records revealed R#32 regained their capacity to make medical decisions on 05/09/19. R#32 receives [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center three days a week. The orders showed Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center) at 12:00pm. (Name of ambulance service) to pick up at 11:30 a.m. An interview with the resident, on 05/14/19 at 09:39 AM, revealed the staff rarely ever takes her blood pressure or ask her anything specific when she returns to the facility from the [MEDICAL TREATMENT] center. R#32 said, They take my blood pressure in the mornings, most of the time. The residents stated the ambulance people that take her helps her back into the bed, and sometimes the nurse comes in and talks to the ambulance people. The resident said she comes back from the [MEDICAL TREATMENT] center with a dressing over her AV access and it is left on till the next day, and sometimes a nurse will look at it when she gets back from [MEDICAL TREATMENT]. An interview with licensed practical nurse (LPN#87), on 05/15/19 at 02:33 PM, revealed nursing staff does not do an assessment of Resident #32 when the resident returns to the facility from the [MEDICAL TREATMENT] center. LPN#87 stated, The ambulance crew returns the resident to her bed and I review the [MEDICAL TREATMENT] communication form to see if there's any new orders. LPN#87 said, If there is an area the [MEDICAL TREATMENT] center did not fill in on the form, like weights, I will call the center and get that information and fill in their part of the form or ask the ambulance crew. I do not document on the communications form any assessment of the resident when she returns back to the facility from the [MEDICAL TREATMENT] center. When asked why there was no post assessment documented, LPN#87 said, The nurses don't do a resident assessment when they return from [MEDICAL TREATMENT]. This surveyor asked if the nurses did any assessment of the resident's vital signs (VS - blood pressure, pulse, temperature, and respirations), the access site for bruits or thrills any swelling, drainage, or pain, or the resident's over all condition upon returning to the facility from the [MEDICAL TREATMENT] center. LPN#87 replied, The bruits are assessed only when scheduled and its document on the MAR (medication administration record) once every shift. No, the nurses don't assess that (bruits and thrills) when they return from the center On 05/15/19 at 03:39 PM review of R#32's care plan revealed [MEDICAL TREATMENT] interventions was addressed in the focus areas of Potential for fluid volume overload/deficit and Alteration in nutritional status. The focus area read Potential for fluid volume overload/deficit related to [MEDICAL CONDITION] requiring [MEDICAL TREATMENT], diuretic use for heart failure,-has port for [MEDICAL TREATMENT] at this time -12/18/18 [MEDICAL TREATMENT] shunt placed to left arm. The goal is Resident will maintain therapeutic fluid volume as evidenced by no fluid volume overload or deficit through next review date Care plan interventions for potential for fluid volume overload/deficit included: Administer diuretic orders as ordered. Check bruit and thrill q (every) shift and PRN (as needed) to left arm [MEDICAL TREATMENT] shunt. Report to MD (medical doctor) if absent. DermacinRx Prizopak Kit 2.5-2.5 % apply to Fistula (left arm) topically as needed for pain, apply 15 mins before [MEDICAL TREATMENT]. [MEDICAL TREATMENT] Monday, Wednesday, and Friday at 12:00 pm. STAT to pick up at 11:30 pm. No blood pressures or sticks to left arm d/t [MEDICAL TREATMENT] shunt. Notify physician of signs and symptoms of fluid volume overload or deficit such as [MEDICAL CONDITION], increased shortness of breath, increased confusion, fluid retention with decreased urinary output, increased cough and congestion, skin tenting, poor skin elasticity, increased thirst. Snack (NAS-No Added Salt) to be sent with resident on [MEDICAL TREATMENT] days Mon, Wed, and Friday. Some care plan interventions for alteration in nutritional status included: Diet as ordered for nutrition. NAS (No Added Salt) diet, Chopped Meats texture, Thin consistency No Orange Juice No Potatoes No Bananas No [NAME]toes. Obtain Labs per order notify MD of results and follow up as indicated. ProMod Liquid related to other Disorders of Plasma-Protein Metabolis. Report to nurse/MD of any signs or symptoms of dehydration such as dry crack lips and skin, poor skin turgor, elevated temp, rapid pulse. Snack bag- Monday, Wednesday, and Friday due to [MEDICAL TREATMENT]. Weights per orders, Notify MD of any significant changes. At 02:43 PM on 05/15/19, review of Resident #32's care plan and the [MEDICAL TREATMENT] communication record with the director of nursing (DON) revealed the care plan had no interventions noted concerning complications related to [MEDICAL TREATMENT]. It was the DON's expectations that residents receiving [MEDICAL TREATMENT] treatments have a pre and post assessment including vital signs before going out to the [MEDICAL TREATMENT] center, and immediately upon their return the facility following [MEDICAL TREATMENT] treatment. The DON confirmed the care plan did not offer directives for pre and/or post [MEDICAL TREATMENT] assessments of the resident, and should have, nor did it direct what to assess, when and how often to assess, nor parameters the facility desired for the vital signs of a [MEDICAL TREATMENT] resident. | 2020-09-01 |