cms_WV: 938
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 938 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 698 | 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 consistently perform pre and post [MEDICAL TREATMENT] resident assessments, before going and/or returning 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: a) Resident #32 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. Review of the [MEDICAL TREATMENT] communication form, on 05/14/19 at 10:45 AM, show the following information was to be provided on the form by the facility before resident went for [MEDICAL TREATMENT] treatment: Resident's name; date; transported by; condition before leaving facility (Lines to write a narrative about the resident's condition); vital signs before [MEDICAL TREATMENT] (blood pressure, pulse, respirations, and temperature); received meal; and sent snack with resident. Information the [MEDICAL TREATMENT] center was to provide on the communication form was as follows: weight before; weight after; date of physicians visits at [MEDICAL TREATMENT]; labs drawn at [MEDICAL TREATMENT]; problems at [MEDICAL TREATMENT]; medications given; new orders; and vital signs before leaving [MEDICAL TREATMENT]. Review of the past month's [MEDICAL TREATMENT] communication sheets, starting 04/17/19 through 05/15/19, revealed on 04/17/19 the facility filled out the information except whether or not the resident received a meal. On 04/19/19 the facility did not send the [MEDICAL TREATMENT] center any information; the [MEDICAL TREATMENT] center however did send back to the facility a different communication sheet with their required information filled in. On 04/22/19 the facility filled out the information except whether the resident received a meal. On 04/24/19, 04/26/19, 04/29/19, 05/01/19, 05/06/19, 05/08/19, 05/10/19, and 05/13/19 only the resident's name; date; and vital signs were filled in. On 05/03/19 information missing on the form was the condition the resident was in before leaving the facility whether she received a meal or if a snack was sent with her. On 05/15/19 all information from the facility was completed. The [MEDICAL TREATMENT] communication form did not have a section for the resident's assessment upon return to the facility after [MEDICAL TREATMENT] treatment, as often seen on [MEDICAL TREATMENT] communication forms. Review of records, on 05/14/19 at 10:45 AM, revealed various nurse progress notes stating .resident is out at this time to [MEDICAL TREATMENT]. Resident clean, dry, and odor free. The few progress notes that mentioned the resident had returned to the facility, had information from the [MEDICAL TREATMENT] center placed in the note, but no notation or evidence of the facility nurse themselves assessing the resident. Example is a nursing note dated 05/10/19 .Vitals after [MEDICAL TREATMENT]: Blood pressure: 112/77, Pulse: 73, Reparations: 16, Temperature: 98.4, Weight: 115 kg per [MEDICAL TREATMENT] Communication form. An interview with the resident, on 05/14/19 at 09:39 AM, revealed the staff rarely if ever takes her blood pressure when she returns from [MEDICAL TREATMENT] treatment, or ever listens to her AV access with a stethoscope, 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]. On 05/15/19 at 01:25 PM review of orders revealed, [MEDICAL TREATMENT] Monday, Wednesday, and Friday at 12:00 PM. (Name of ambulance service) to pick up at 11:30 AM. No blood pressures or IV sticks to left arm due to fistula graft. Check bruit and thrill to left brachial [MEDICAL TREATMENT] fistula q (every) shift and prn (as needed). 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 where the post [MEDICAL TREATMENT] assessment was 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); 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 At 02:43 PM on 05/15/19, review of Resident #32's the [MEDICAL TREATMENT] communication record and care plan with the director of nursing (DON) revealed the [MEDICAL TREATMENT] communication record did not include an area to document a post [MEDICAL TREATMENT] assessment, the facility nurses should perform. 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 upon their return the facility following [MEDICAL TREATMENT] treatment. When asked if the nurses did any assessment of the resident's vital signs (VS - blood pressure, pulse, temperature, and respirations); access site for bruits or thrills any swelling, drainage, or pain; or the resident's condition upon returning to the facility from the [MEDICAL TREATMENT] center, the DON confirmed they should be. When asked where the nurses should be documenting their assessment of the resident when returning from [MEDICAL TREATMENT] treatments the DON said it should be at least in the nurses' progress note. The DON said, The bruit and thrill is done every shift and is documented on the MAR. The DON confirmed the order for checking the bruit and thrill PRN (as needed) would be when the resident had a problem or when they returned from [MEDICAL TREATMENT]. This surveyor requested any evidence that any post [MEDICAL TREATMENT] treatment assessments were being done by the facility when the resident return to the facility from the [MEDICAL TREATMENT] center, upon exit no evidence was provided. | 2020-09-01 |