MORGANTOWN CARE & REHABILITATION CENTER
LOCATED: 201 SOUTH WARREN STREET, MORGANTOWN, KY 42261
MORGANTOWN CARE & REHABILITATION CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO IMMEDIATELY TELL THE RESIDENT, THE RESIDENT’S DOCTOR AND A FAMILY MEMBER OF THE RESIDENT OF SITUATIONS (INJURY/DECLINE/ROOM, ETC.) THAT AFFECT THE RESIDENT.
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, facility policy and procedure review, and review of hospital records, it was determined the facility failed to consult with the resident’s physician and notify the resident’s interested family member, when there was an accident which resulted in injury and had the potential for requiring physician intervention for one (1) of three (3) sampled residents (Resident #1).
Resident #1, who was on blood thinners, sustained a fall on 08/06/16 at approximately 2:00 AM, which resulted in two (2) hematomas to the back of the head; however, Licensed Practical Nurse (LPN) #2 failed to notify the physician and family of the fall with injury per facility policy. In addition, Resident #1 complained of head pain at 3:00 AM when he/she was administered pain medication and was still complaining of head pain and requesting an ice pack at 4:15 AM. However, the nurse did not follow facility policy, and notify the physician that the resident’s pain medication was ineffective. At approximately 6:15 AM-6:30 AM, Resident #1 was found unresponsive with his/her pupils fixed. Resident #1 was transported to the hospital and diagnosed with [REDACTED]. The resident passed away at approximately 11:23 PM.
Interview with the Director of Nursing (DON), on 08/12/16 at 3:10 AM and on 08/16/16 at 3:10 PM, revealed she expected the nurse to notify the physician and family after a fall. She stated she also expected the nurse to assess the resident after administering an as needed pain medication to determine if it was effective or not. She stated if the pain medication was not effective the physician would need to be contacted for further orders.
Interview, on 08/15/16 at 10:05 AM, with Resident #1’s attending Physician, who is also the facility’s Medical Director, revealed he would have expected the nurse to make him or the on call physician aware of the fall especially since the resident had a head injury and he/she was on blood thinners. He stated he would have sent the resident out to the hospital for a Computer Topography (CT) scan of the head. He stated because the resident was on a blood thinner he/she was at a higher risk of a subdural hematoma.
Interview with the Administrator on 08/16/16 at 3:25 PM, revealed she expected the nurses to notify the physician and family by phone immediately after a fall. She stated she also expected them to follow the facility’s policy related to determining the effectiveness of pain medication and physician notification.
Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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