rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
3912,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,159,E,0,1,VTNG11,"Based on record review and staff interview, the facility failed to safeguard, manage, and account for the residents' personal funds deposited with the facility in accordance with regulations. The facility failed to ensure the resident/responsible party received quarterly notices for two (2) of three (3) reviewed, and/or failed to ensure residents who received Medicaid were notified the account reached $200 less than the Social Security Income (SSI) resource limit for four (4) of five (5) resident accounts reviewed. Resident identifiers: #59, #8, #109, #21, and 119. Facility Census: 109. a) Residents #109, #8, #119, #59 A financial record review, on 11/03/6 at 11:27 a.m., with Business Office Manager (BOM) #84, revealed the above residents received Medicaid services and had greater than $1800 in the Resident Funds account. The BOM reviewed the financial records and stated the accounts contained amounts greater than $1,800. b) Resident #59 The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 08/08/16 noted a brief interview for mental status (BIMS) score of 14, which indicated Resident #59 was cognitively intact. The resident fund management statement noted account balances greater than $1,800 dollars for: --November (YEAR) for three (3) of three (3) days --October (YEAR) for thirty-one (31) of thirty-one (31) days --September (YEAR) for thirty (30) of thirty (30) --August (YEAR) for thirty-one of thirty-one days --July (YEAR) for twenty-three (23) of thirty-one (31) days BOM #84 provided a copy of a letter, dated 10/20/16 related to notification of funds. Both the signature of the facility representative and resident acknowledgement were blank. The acknowledgement of receipt of resident trust, dated 10/20/16 was also contained no signatures. c) Resident 8 Resident #8 ' s financial record indicated the resident's account contained greater than $1,800 dollars for: --November (YEAR) for three (3) of three (3) days --October (YEAR) for thirty-one (31) of thirty-one (31) days --September (YEAR) for twenty-nine (29) of thirty (30) days d) Resident #109 The account of Resident #109 exceeded $1,800 as follows: --November (YEAR) for three (3) of three (3) days --October (YEAR) for twenty-two (22) of thirty-one (31) days --September (YEAR) for twenty-one (21) of thirty (30) days --August (YEAR) for fourteen (14) of thirty-one (31) days e) Resident #119's The account of Resident #119 exceeded $1,800 for --November (YEAR) for three (3) of three (3) days --October (YEAR) for thirty-one (31) of thirty-one (31) days --September (YEAR) for twenty (20) of thirty (30) days b) Resident #59 and #21 The BOM, interviewed on 11/03/16 between 11:27 a.m. and 11:50 a.m., reviewed the financial and medical records of Resident #59 and #21. She voiced she was unable to verify the resident and/or responsible party had received a quarterly statement. : BOM related Resident #21 had an account balance of zero dollars ($0.00) due to the money had been transferred into the facility's account.",2020-04-01
3913,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,160,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record and staff interview the facility failed to convey personal funds in accordance with regulations upon death. This practice affected three (3) residents but had the potential to affect all residents who had a personal funds account upon death. Facility census: 109 Resident identifiers: Facility census: 109. Resident identifiers: Resident #13, #58 and #112. Findings include: a) Resident #13, #58 and #112 A financial record review, with Business Office Manager (BOM) #84, on [DATE] at 11:31 a.m., revealed the above residents had a Resident Funds Account with the facility, and had expired within the previous three (3) to six (6) months. The residents' accounts, reviewed with the BOM revealed the facility had not conveyed the deceased residents' personal funds and a final accounting to the individual or probate jurisdiction administering the individual's estate, within 30 days, as provided by State law. b) Resident #58 expired on [DATE] and the account noted a pending amount of $1,131.49. c) Resident #13 expired on [DATE] and had an account balance of $865.58. d) Resident #112 expired on [DATE] and a check in the amount of $36.01 was made payable to the facility on [DATE]. e) The BOM reviewed the financial records and medical record and voiced no information was present to indicate each resident's responsible party had been notified of the account balance, and acknowledged the accounts had not been conveyed to the responsible parties within thirty (30) days as required.",2020-04-01
3914,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,161,E,0,1,VTNG11,"Based on financial record review and staff interview, the facility failed to purchase a Surety bond to ensure the security of all personal funds of residents deposited with the facility. Resident Funds accounts exceeded the amount of the surety bond. This practice had the potential to affect more than a limited number of residents. Facility census: 109. Findings include: a) The Surety bond, reviewed on 11/02/16, revealed a bond in the amount of one hundred twenty thousand dollars ($120,000). The bank statement daily balances, dated 07/01/16 through 10/31/16, reviewed on 11/03/16 at 8:55 a.m., noted balances in excess of the bond as follows: --$144,052.14 on 09/12/16 --$139,836.84 on 09/11/16, 09/10/16, and 09/09/16 --$140,068.84 on 09/08/16 --$140,168.84 on 09/07/16 --$141,794.92 on 09/06/16, 09/05/16, 09/04/16, 09/03/16, and 09/02/16 --$140,115.42 on 08/09/16 --$140,220.42 on 08/08/16 --$140,310.42 on 08/07/16, 08/06/16 and 08/05/16 --$139,880.50 on 08/04/16 and 08/03/16 --$128,339.92 on 07/06/16 --$128,150.22 on 07/05/16 --$126,230.47 on 07/04/16, 07/03/16, 07/02/16 and 07/01/16 The administrator acknowledged during an interview at about 10:30 a.m., the daily funds exceed the amount of the Surety bond.",2020-04-01
3915,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,223,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure one (1) of one (1) residents reviewed for abuse, were free from physical, emotional, mental and/or sexual abuse. A male resident allegedly grabbed Resident #164's arm and tried to push her hand down toward his private area. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our general conversation and told me it was Resident name (Resident #79). Review of the facility grievances/concern forms on 11/02/16 at 10:45 a.m. revealed a form dated 10/31/16 concerning Resident #164. Documentation of the incident stated (typed as written): --Resident name (Resident #164) stated another resident (Resident initials of Resident #79) was attempting to grab her hand. She said she pulled her hand away. She said that she did not feel uncomfortable with the situation that it was no big deal. She said that (Resident initials of Resident #79) was a friend of her husband. Attached to the form was a statement by ST #31. Also attached was an interview statement of Resident #79 interviewed by the Nursing Home Administrator (NHA). The initial statement of the interview (typed as written) states; I spoke with (Resident #79) related to an alleged advance that he may have made on a female resident. During an interview with Social Services Director (SSD) #54 on 11/03/2016 at 8:22 a.m., she commented, the other resident (Resident #79) had been a friend of her husband and was grabbing for her hand. The SSD #54 said she informed the Director of Nursing (DON) and completed a grievance/concern form. She reported the resident did not seem uncomfortable, nor did she expand about the incident. Upon further inquiry SSD #54 stated, Since she (Resident #164) just said he grabbed my hand, I didn't ask her to expand on the situation. Sometimes when people know each other they will sometimes just grab your hands as a greeting, so I assumed that was all it was. When asked if SSD #54 used the word abuse during the resident interview was the word abuse used, the SSD #54 stated, No I just used the word unsafe because sometimes the word abuse will upset a resident, but I will interview her again. Maybe I didn't ask enough questions and ask her to explain more the first time. Upon further inquiry after reviewing the Grievance/Concern form, she did not reply when asked if it should have been investigated as an allegation of sexual abuse. SSD #54 stated, If she would have felt unsafe or uncomfortable about the incident I would have reported it. She did not reply when asked again if this allegation should have been investigated and reported as an alleged abuse allegation. She did state, The investigation is not complete yet because we just received it on Monday and no interventions have been put into place because it was just a concern nor was it seen as an incident or reported to any state agencies. Resident #164 commented tearfully during a follow-up interview with on 11/03/2016 at 9:06 a.m., that the Social Worker had just been in her room. The Resident stated, I told her the same thing I told you yesterday (11/01/16) and the same thing I had told her on Monday (10/31/16), that Resident name (Resident #79) grabbed my arm to pull my hand down toward his private area. I didn't tell you his name yesterday though because I didn't think you would know who he was, but I had told her (SSD #54) his name. His (Resident #79) room is down here somewhere and every time he goes past my room, he (Resident #79) just stares at me. Resident #164 was tearful and visibly upset during the interview stating, They just don't want to believe things like this happen here and how upsetting it is for this to happen to a person. SSD #54 reported on 11/03/2016 at 9:19 a.m., that she had spoken with Resident #164 and she (Resident #164) had stated, the male resident had grabbed her hands and she motioned toward down. SSD #54 commented she would talk with the NHA and report this issue now as an allegation of sexual abuse. She explained the process that each morning the incidents/accidents and grievances/concerns are reviewed in the department meetings and after reviewing these determine whether to report any allegations. The SSD #54 stated, Maybe I should have asked more questions on Monday (10/31/16) of the resident and completed a better investigation. Review of the medical record on 11/03/16 at 9:36 a.m. revealed Resident #164 was admitted in (MONTH) (YEAR), her [DIAGNOSES REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/28/16 showed a brief interview for mental status (BIMS) score of 13, indicating the resident has intact cognitive function. Resident #164 has the capacity to make medical decisions as documented by her attending Physician on admission to the facility. The NHA reported during an interview on 11/03/16 at 10:00 a.m., We are currently in the process of reporting the alleged sexual abuse to the appropriate state agencies. He agreed the facility did not identify the allegation as sexual harassment or abuse, report to the appropriate State agencies and investigate appropriately. Employees are educated annually to recognize and report abuse and neglect. Upon inquiry as to why the allegation was not reported when it was discovered, he stated, We went with the interview information that we had, but I did not realize it was insufficient. He did not reply when inquired as to why the verbiage advances was used in his interview with Resident #79, but not treated as an allegation of sexual harassment and/or abuse. A review of the facility Abuse Prohibition Policy and Procedure for the included the following: --Identification of possible incidents or allegations which need investigation. --Investigation of incidents and allegations. --Protection of patients during investigations. --Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Upon receiving information concerning a report of suspected or alleged abuse, neglect report to appropriate State agencies. --Conduct an immediate and thorough investigation that focuses on whether abuse or neglect occurred and to what extent.",2020-04-01
3916,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,225,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, personnel record review, staff interview, and policy review, the facility failed to screen personnel for a background of abuse, neglect or mistreatment and investigate and report allegations of abuse. The facility failed to identify, thoroughly investigate and/or report timely allegations of physical, emotional, mental and/or sexual abuse to the appropriate State agencies. This practice has the potential to affect more than a limited number of residents. The facility also failed to operationalize policies and procedures related to completion of criminal background checks as required, for one (1) of ten (10) employees reviewed and failed to implement policies and procedures related to reporting and/or a thorough investigation of allegations of abuse. This practice affected one (1) of one (1) residents reviewed for abuse, and had the potential to affect more than a limited number of residents. Facility census: 109. Resident identifier: Resident #164. Employee identifier: Nurse Aide (NA) #20. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our general conversation and told me it was Resident name (Resident #79). Review of the facility grievances/concern forms on 11/02/16 at 10:45 a.m. revealed a form dated 10/31/16 concerning Resident #164. Documentation of the incident stated (typed as written): Resident name (Resident #164) stated another resident (Resident initials of Resident #79) was attempting to grab her hand. She said she pulled her hand away. She said that she did not feel uncomfortable with the situation that it was no big deal. She said that (Resident initials of Resident #79) was a friend of her husband. Attached to the form was a statement by ST #31. Also attached was an interview statement of Resident #79 interviewed by the Nursing Home Administrator (NHA). The initial statement of the interview (typed as written) states; I spoke with (Resident #79) related to an alleged advance that he may have made on a female resident. During an interview with Social Services Director (SSD) #54 on 11/03/2016 at 8:22 a.m., she commented, the other resident (Resident #79) had been a friend of her husband and was grabbing for her hand. The SSD #54 said she informed the Director of Nursing (DON) and completed a grievance/concern form. She reported the resident did not seem uncomfortable, nor did she expand about the incident. Upon further inquiry SSD #54 stated, Since she (Resident #164) just said he grabbed my hand, I didn't ask her to expand on the situation. Sometimes when people know each other they will sometimes just grab your hands as a greeting, so I assumed that was all it was. When asked if SSD #54 used the word abuse during the resident interview was the word abuse used, the SSD #54 stated, No I just used the word unsafe because sometimes the word abuse will upset a resident, but I will interview her again. Maybe I didn't ask enough questions and ask her to explain more the first time. Upon further inquiry after reviewing the Grievance/Concern form, she did not reply when asked if it should have been investigated as an allegation of sexual abuse. SSD #54 stated, If she would have felt unsafe or uncomfortable about the incident I would have reported it. She did not reply when asked again if this allegation should have been investigated and reported as an alleged abuse allegation. She did state, The investigation is not complete yet because we just received it on Monday and no interventions have been put into place because it was just a concern nor was it seen as an incident or reported to any state agencies. Resident #164 commented tearfully during a follow-up interview with on 11/03/2016 at 9:06 a.m., that the Social Worker had just been in her room. The Resident stated, I told her the same thing I told you yesterday (11/01/16) and the same thing I had told her on Monday (10/31/16), that Resident name (Resident #79) grabbed my arm to pull my hand down toward his private area. I didn't tell you his name yesterday though because I didn't think you would know who he was, but I had told her (SSD #54) his name. His (Resident #79) room is down here somewhere and every time he goes past my room, he (Resident #79) just stares at me. Resident #164 was tearful and visibly upset during the interview stating, They just don't want to believe things like this happen here and how upsetting it is for this to happen to a person. SSD #54 reported on 11/03/2016 at 9:19 a.m., that she had spoken with Resident #164 and she (Resident #164) had stated, the male resident had grabbed her hands and she motioned toward down. SSD #54 commented she would talk with the NHA and report this issue now as an allegation of sexual abuse. She explained the process that each morning the incidents/accidents and grievances/concerns are reviewed in the department meetings and after reviewing these determine whether to report any allegations. The SSD #54 stated, Maybe I should have asked more questions on Monday (10/31/16) of the resident and completed a better investigation. Review of the medical record on 11/03/2016 at 9:36 a.m. revealed Resident #164 was admitted on [DATE], her [DIAGNOSES REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/28/16 showed a brief interview for mental status (BIMS) score of 13, indicating the resident has intact cognitive function. Resident #164 has the capacity to make medical decisions as documented by her attending Physician on admission to the facility. The NHA reported during an interview on 11/03/16 at 10:00 a.m., We are currently in the process of reporting the alleged sexual abuse to the appropriate state agencies. He agreed the facility did not identify the allegation as sexual harassment or abuse, report to the appropriate State agencies and investigate appropriately. Employees are educated annually to recognize and report abuse and neglect. Upon inquiry as to why the allegation was not reported when it was discovered, he stated, We went with the interview information that we had, but I did not realize it was insufficient. He did not reply when inquired as to why the verbiage advances was used in his interview with Resident #79, but not treated as an allegation of sexual harassment and/or abuse. A review of the facility Abuse Prohibition Policy and Procedure for the included the following: --Identification of possible incidents or allegations which need investigation. --Investigation of incidents and allegations. --Protection of patients during investigations. --Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Upon receiving information concerning a report of suspected or alleged abuse, neglect report to appropriate State agencies. --Conduct an immediate and thorough investigation that focuses on whether abuse or neglect occurred and to what extent. b) Criminal background checks During a personnel record review related to criminal background checks, with the Human Resources Regional Director (HRRD) #150, on 11/02/16 at 2:30 p.m., the director provided a copy of a State police background check, dated 12/07/15 for Nurse Aide (NA) #20, who was hired on 11/19/15. Upon inquiry, the director related no information was present to indicate the facility had entered the NA into the West Virginia (WV) Cares system. The administrator, interviewed at 2:40 p.m., said the WV Cares form was completed on paper on 11/11/15 and submitted, and was informed at a later time that he had to submit it electronically. The administrator provided a copy of the bill from Morphotrust, which noted a payment in the amount required for only a State background check. He confirmed a federal background check had not been completed. The SAFRAN MorphoTrust USA guideline, with a revision date of Sept (YEAR) (September (YEAR)) was currently doing the fingerprinting for WV CARES for both a West Virginia (WV) and Federal Bureau of Investigation (FBI) background check. Communications between MorphoTrust and WV Cares, dated 11/02/16, noted WV CARES won't (will not) have the result. WV Cares was not the agency of record, nor was a FBI (Federal Bureau of Investigation) check done. If the applicant needs processed under WV CARES, she will need to be printed again either in one of our livescan locations or we will need to get another set of fingerprint cards with the agency noted as WV CARES. We do not keep cards after 90 days, so our cardscan team does not have anything to research. The time card, reviewed on 11/03/16 indicated Employee #20 had worked at the facility as recently as 11/01/16, and the other number of days for August, (MONTH) and (MONTH) of (YEAR): --October (YEAR) the NA worked twenty-three (23) of thirty-one (31) days; --September (YEAR) the NA worked twenty-one (21) of thirty (30) days; and --August (YEAR) the NA worked twenty-two (22) of thirty-one (31) days. The administrator acknowledged, during an interview on 11/03/16, the facility did not follow-up to ensure Nurse Aide #20 had been entered into the WV-CARES system.",2020-04-01
3917,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,226,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review and policy/procedure review, the facility failed to implement its written policies and procedures to ensure one (1) of one (1) residents reviewed for abuse, were free from physical, emotional, mental and/or sexual abuse. A male resident allegedly grabbed Resident #164's arm and tried to push her hand down toward his private area. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our general conversation and told me it was Resident name (Resident #79). Review of the facility grievances/concern forms on 11/02/16 at 10:45 a.m. revealed a form dated 10/31/16 concerning Resident #164. Documentation of the incident stated (typed as written): Resident name (Resident #164) stated another resident (Resident initials of Resident #79) was attempting to grab her hand. She said she pulled her hand away. She said that she did not feel uncomfortable with the situation that it was no big deal. She said that (Resident initials of Resident #79) was a friend of her husband. Attached to the form was a statement by ST #31. Also attached was an interview statement of Resident #79 interviewed by the Nursing Home Administrator (NHA). The initial statement of the interview (typed as written) states; I spoke with (Resident #79) related to an alleged advance that he may have made on a female resident. During an interview with Social Services Director (SSD) #54 on 11/03/2016 at 8:22 a.m., she commented, the other resident (Resident #79) had been a friend of her husband and was grabbing for her hand. The SSD #54 said she informed the Director of Nursing (DON) and completed a grievance/concern form. She reported the resident did not seem uncomfortable, nor did she expand about the incident. Upon further inquiry SSD #54 stated, Since she (Resident #164) just said he grabbed my hand, I didn't ask her to expand on the situation. Sometimes when people know each other they will sometimes just grab your hands as a greeting, so I assumed that was all it was. When asked if SSD #54 used the word abuse during the resident interview was the word abuse used, the SSD #54 stated, No I just used the word unsafe because sometimes the word abuse will upset a resident, but I will interview her again. Maybe I didn't ask enough questions and ask her to explain more the first time. Upon further inquiry after reviewing the Grievance/Concern form, she did not reply when asked if it should have been investigated as an allegation of sexual abuse. SSD #54 stated, If she would have felt unsafe or uncomfortable about the incident I would have reported it. She did not reply when asked again if this allegation should have been investigated and reported as an alleged abuse allegation. She did state, The investigation is not complete yet because we just received it on Monday and no interventions have been put into place because it was just a concern nor was it seen as an incident or reported to any state agencies. Resident #164 commented tearfully during a follow-up interview with on 11/03/2016 at 9:06 a.m., that the Social Worker had just been in her room. The Resident stated, I told her the same thing I told you yesterday (11/01/16) and the same thing I had told her on Monday (10/31/16), that Resident name (Resident #79) grabbed my arm to pull my hand down toward his private area. I didn't tell you his name yesterday though because I didn't think you would know who he was, but I had told her (SSD #54) his name. His (Resident #79) room is down here somewhere and every time he goes past my room, he (Resident #79) just stares at me. Resident #164 was tearful and visibly upset during the interview stating, They just don't want to believe things like this happen here and how upsetting it is for this to happen to a person. SSD #54 reported on 11/03/2016 at 9:19 a.m., that she had spoken with Resident #164 and she (Resident #164) had stated, the male resident had grabbed her hands and she motioned toward down. SSD #54 commented she would talk with the NHA and report this issue now as an allegation of sexual abuse. She explained the process that each morning the incidents/accidents and grievances/concerns are reviewed in the department meetings and after reviewing these determine whether to report any allegations. The SSD #54 stated, Maybe I should have asked more questions on Monday (10/31/16) of the resident and completed a better investigation. Review of the medical record on 11/03/16 at 9:36 a.m. revealed Resident #164 was admitted in (MONTH) (YEAR), her [DIAGNOSES REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/28/16 showed a brief interview for mental status (BIMS) score of 13, indicating the resident has intact cognitive function. Resident #164 has the capacity to make medical decisions as documented by her attending physician on admission to the facility. The NHA reported during an interview on 11/03/16 at 10:00 a.m., We are currently in the process of reporting the alleged sexual abuse to the appropriate state agencies. He agreed the facility did not identify the allegation as sexual harassment or abuse, report to the appropriate State agencies and investigate appropriately. Employees are educated annually to recognize and report abuse and neglect. Upon inquiry as to why the allegation was not reported when it was discovered, he stated, We went with the interview information that we had, but I did not realize it was insufficient. He did not reply when inquired as to why the verbiage advances was used in his interview with Resident #79, but not treated as an allegation of sexual harassment and/or abuse. A review of the facility Abuse Prohibition Policy and Procedure for the included the following: --Identification of possible incidents or allegations which need investigation. --Investigation of incidents and allegations. --Protection of patients during investigations. --Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Upon receiving information concerning a report of suspected or alleged abuse, neglect report to appropriate State agencies. --Conduct an immediate and thorough investigation that focuses on whether abuse or neglect occurred and to what extent.",2020-04-01
3918,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,241,D,0,1,VTNG11,"Based on observation, record review, resident interview and staff interview, the facility failed to promote care for residents in a manner that maintained each resident's dignity and respect in full recognition of their identity. Resident #68 experienced a prolonged wait time for lunch to be served. Resident #132 was transferred by the use of his armpits. This failed practice caused affected to two (2) of four (4) residents reviewed. Resident identifiers: #68 and #132. Facility census: 109. a) Resident #68 On 10/31/16 at 12:45 p.m. in the Fiesta Dining Room (Dining room A), observation revealed a refused meal for Resident #68. A resident seated at the table stated that Resident #68 waited over an hour for lunch, and said he was not waiting any longer and left the dining room. During an interview on 10/31/16 at 12:48 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 did not eat lunch today. Review of Resident #68's medical record on 11/01/16 at 8:00 a.m., showed the activities of daily living (ADL) record dated 10/31/16 failed to reflect Resident #68's meal refusal. During a resident interview, on 11/01/2016 at 8:49 a.m., Resident #68 stated, I didn't like sitting there like a welfare case that lunch was going to be late. Why should you want to sit for an hour and five minutes for something to eat? I would never treat people like this. During a resident interview on 11/02/16 at 11:26 a.m., Resident #68 stated, It was an insult, I felt at their mercy. I don't expect luxury, but they should have had the courtesy to tell me it (lunch) was going to be late and by the time they served me, it was an hour. I feel like I have a boss. Review of Resident #68's medical record on 11/02/2016 at 10:50 a.m. showed a care plan stating that Resident #68 had potential for psycho social impairment due to difficulty adjusting to new environment. b) Resident #132 During a Stage 1 observation and interview on 11/01/16 at 9:48 a.m., observation revealed Resident #132 seated in a chair across from the resident lounge. The resident agreed to an interview, but said he required assistance to stand up from the chair. A male employee, who identified himself as a Central Supply employee (CS) #123 said he was not able to assist because he was not a nurse aide (NA), but would request help. CS #123 returned with a nurse aide (NA). The NA placed an arm under Resident #132's right axilla (armpit) and CS #123 placed an arm under the resident's left axilla, assisting him to a standing position. Resident #132 said staff did not recognize him as a person, and felt he was not treated with dignity. The resident stated that staff walked by him without acknowledging him. The resident further stated, All I want is for them to see me as a person. An interview with Licensed Practical Nurse (LPN) #64, on 11/03/16, said staff should not lift under the arms, but did not know whether it was a dignity issue. The director of nursing (DON) interviewed at 1:52 p.m. said, It's (it is) not dignified and that the facility had the proper equipment.",2020-04-01
3919,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,242,D,0,1,VTNG11,"Based on observation, resident interview and staff interview, the facility failed to demonstrate that the resident had the right to choose schedules consistent with their interests and make choices about aspects of their life that were significant to the resident. The facility failed to inform a resident of a prolonged wait during a meal service, prohibiting the resident to make an informed choice. This was a random observation affecting Resident #68. Facility census: 109. On 10/31/16 at 12:45 p.m. in the Fiesta Dining Room (Dining room A), observation revealed a refused meal for Resident #68. A resident seated at the table stated that Resident #68 waited over an hour for lunch, and said he was not waiting any longer and left the dining room. During an interview on 10/31/16 at 12:48 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 did not eat lunch today. Review of Resident #68's medical record on 11/01/16 at 8:00 a.m., showed the activities of daily living (ADL) record dated 10/31/16 failed to reflect Resident #68's meal refusal. During a resident interview on 11/02/16 at 11:26 a.m., Resident #68 stated, It was an insult, I felt at their mercy. I don't expect luxury, but they should have had the courtesy to tell me it (lunch) was going to be late and by the time they served me, it was an hour. I feel like I have a boss. Review of Resident #68's medical record on 11/02/2016 at 10:50 a.m. showed a care plan stating that Resident #68 had potential for psycho social impairment due to difficulty adjusting to new environment. During a resident interview, on 11/01/2016 at 8:49 a.m., Resident #68 stated, I didn't like sitting there like a welfare case that lunch was going to be late. Why should you want to sit for an hour and five minutes for something to eat? I would never treat people like this. During a staff interview on 11/02/16 at 10:32 a.m. the Food Service Director (FSD), stated, Some residents are always served last. They (facility) needs to try to rotate the serving order if they can, so that it shouldn't happen as much. It used to happen more often.",2020-04-01
3920,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,250,D,0,1,VTNG11,"Based on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure the provision of medically related social services were sufficient and appropriate to meet resident needs. The facility failed to identify and thoroughly investigate an alleged allegations of physical, emotional, mental and/or sexual abuse. This practice affected one (1) of one (1) residents reviewed for abuse and has the potential to affect more than a limited number of residents. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our general conversation and told me it was Resident name (Resident #79). Review of the facility grievances/concern forms on 11/02/16 at 10:45 a.m. revealed a form dated 10/31/16 concerning Resident #164. Documentation of the incident stated (typed as written): Resident name (Resident #164) stated another resident (Resident initials of Resident #79) was attempting to grab her hand. She said she pulled her hand away. She said that she did not feel uncomfortable with the situation that it was no big deal. She said that (Resident initials of Resident #79) was a friend of her husband. Attached to the form was a statement by ST #31. Also attached was an interview statement of Resident #79 interviewed by the Nursing Home Administrator (NHA). The initial statement of the interview (typed as written) states; I spoke with (Resident #79) related to an alleged advance that he may have made on a female resident. During an interview with Social Services Director (SSD) #54 on 11/03/2016 at 8:22 a.m., she commented, the other resident (Resident #79) had been a friend of her husband and was grabbing for her hand. The SSD #54 said she informed the Director of Nursing (DON) and completed a grievance/concern form. She reported the resident did not seem uncomfortable, nor did she expand about the incident. Upon further inquiry SSD #54 stated, Since she (Resident #164) just said he grabbed my hand, I didn't ask her to expand on the situation. Sometimes when people know each other they will sometimes just grab your hands as a greeting, so I assumed that was all it was. When asked if SSD #54 used the word abuse during the resident interview was the word abuse used, the SSD #54 stated, No I just used the word unsafe because sometimes the word abuse will upset a resident, but I will interview her again. Maybe I didn't ask enough questions and ask her to explain more the first time. Upon further inquiry after reviewing the Grievance/Concern form, she did not reply when asked if it should have been investigated as an allegation of sexual abuse. SSD #54 stated, If she would have felt unsafe or uncomfortable about the incident I would have reported it. She did not reply when asked again if this allegation should have been investigated and reported as an alleged abuse allegation. She did state, The investigation is not complete yet because we just received it on Monday and no interventions have been put into place because it was just a concern nor was it seen as an incident or reported to any state agencies. Resident #164 commented tearfully during a follow-up interview with on 11/03/2016 at 9:06 a.m., that the Social Worker had just been in her room. The Resident stated, I told her the same thing I told you yesterday (11/01/16) and the same thing I had told her on Monday (10/31/16), that Resident name (Resident #79) grabbed my arm to pull my hand down toward his private area. I didn't tell you his name yesterday though because I didn't think you would know who he was, but I had told her (SSD #54) his name. His (Resident #79) room is down here somewhere and every time he goes past my room, he (Resident #79) just stares at me. Resident #164 was tearful and visibly upset during the interview stating, They just don't want to believe things like this happen here and how upsetting it is for this to happen to a person. SSD #54 reported on 11/03/2016 at 9:19 a.m., that she had spoken with Resident #164 and she (Resident #164) had stated, the male resident had grabbed her hands and she motioned toward down. SSD #54 commented she would talk with the NHA and report this issue now as an allegation of sexual abuse. She explained the process that each morning the incidents/accidents and grievances/concerns are reviewed in the department meetings and after reviewing these determine whether to report any allegations. The SSD #54 stated, Maybe I should have asked more questions on Monday (10/31/16) of the resident and completed a better investigation. Resident #164 has the capacity to make medical decisions as documented by her attending physician on admission to the facility. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/28/16 showed a brief interview for mental status (BIMS) score of 13, indicating the Resident #164 has intact cognitive function. Resident #164 has the capacity to make medical decisions as documented by her attending physician on admission to the facility. The NHA reported during an interview on 11/03/16 at 10:00 a.m., We are currently in the process of reporting the alleged sexual abuse to the appropriate state agencies. He agreed the facility did not identify the allegation as sexual harassment or abuse, report to the appropriate State agencies and investigate appropriately. Employees are educated annually to recognize and report abuse and neglect. Upon inquiry as to why the allegation was not reported when it was discovered, he stated, We went with the interview information that we had, but I did not realize it was insufficient. He did not reply when inquired as to why the verbiage advances was used in his interview with Resident #79, but not treated as an allegation of sexual harassment and/or abuse. A review of the facility Abuse Prohibition Policy and Procedure for the included the following: --Identification of possible incidents or allegations which need investigation. --Investigation of incidents and allegations. --Protection of patients during investigations. --Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Upon receiving information concerning a report of suspected or alleged abuse, neglect report to appropriate State agencies. --Conduct an immediate and thorough investigation that focuses on whether abuse or neglect occurred and to what extent.",2020-04-01
3921,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,253,E,0,1,VTNG11,"Based on observation, facility guidelines and staff interviews, the facility to provide housekeeping and maintenance services necessary to ensure an orderly, sanitary, and comfortable environment by not performing routine and/or preventative maintenance services on oxygen concentrators and resident rooms and/or bathrooms. This affected more than a limited number of residents. Resident room identifiers: #170, #173, #175, #181, #236, #237 and #347. Resident identifiers for the concentrators: #162, #64, #114, #143 and #29. Facility census 109. Findings include: a) Cosmetic imperfections On 11/02/16 observations began at 11:00 a.m., with the Maintenance Supervisor, found the following cosmetic imperfections. --The bathroom commode in Room #170 had yellow, brown discoloration around the base of commode. There were caulking missing from the molding on the top right back side of the bathroom wall. --The bathroom in between Rooms #173 and #175, had the caulking missing and a dark brown discoloration at the doorway entrance of the bathroom. The paint was peeling from the right lower corner of the wall, and on the right side of the wall facing the commode. The caulking was no longer present and the molding is pulled away on the right side behind the commode. --The bathroom entrance in Room #181 had the caulking missing and a dark brown discoloration. The molding along the back wall behind the commode was pulled away and the caulking missing from the bottom of the molding along the wall to the right upon entering the bathroom. --The bathroom heater located along the bottom of the bathroom in Room #236 had brown color rust in the corner and top, and bottom of the heater. The thermostat knob on the heater was missing. --In Room 237 tile was missing under the sink in the right back corner along the wall. The beside stand was covered in a thick layer of dust with fingerprint smudges near the front on 11/01/16 at 1: 59 p.m., the assistant director of nursing (ADON) #87 said, Yeah, that's pretty bad. --In Room #347 entrance to the bathroom had the threshold missing. In an interview with the Maintenance Supervisor #142 on 11/02/16 at 11:48 a.m. He confirmed the rooms observed with were in need of repair. b) Oxygen Concentrator Maintenance Observations during Stage 1 and Stage 2 of the QIS from 10/31/16 to 11/03/16 found Invacare oxygen concentrators had no preventative maintenance sticker to indicate the last date of service for the following residents: #162, #64, #114, #143, and #29. During an interview and observation with the Maintenance Supervisor #142, on 11/02/16 at 3:00 p.m., the Maintenance Supervisor removed the top off of the oxygen concentrators for residents #162, #64, #114, #143, and #29 to visualize each internal filter. The observation revealed that Residents #162, #64,#114, #143, and #29 oxygen concentrator internal filters had no date of when the last time the filter were changed. He reported the facility had just started conducting their own maintenance on the oxygen concentrators which consisted of changing the internal oxygen filters and writing on the internal oxygen filter the date they changed the filter. The Maintenance Supervisor said they had another employee changing the internal filter and he should have indicated on the filter when the filter was last changed. He said the internal filter is changed every six (6) months. He confirmed that he could not tell me when the oxygen concentrator internal filter for Residents #162, #64, #114, #143, and #29 had been changed since there is no date on the internal filter itself. The Maintenance Supervisor, on 11/02/16 at 3:30 p.m., provided the facility's guideline on preventative maintenance record for the oxygen concentrators. The guideline revealed the internal filters are required to be changed every six (6) month.",2020-04-01
3922,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,272,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct an accurate comprehensive assessment for one (1) of one (1) Stage 2 sample residents reviewed for Hospice services. Resident #26's assessment did not identify receiving Hospice services. Resident identifier: #26. Facility census: 109. Findings include: a) Resident #26 On 11/03/2016 at 11:51 a.m. review of the resident's medical record revealed [REDACTED]. The significant change minimum data set (MDS) with an assessment reference date (ARD) of 09/30/16 did not identify the resident as receiving Hospice services in section O0100. Clinical Reimbursement Coordinator (CRC) #11 reviewed this MDS with an ARD of 09/30/16 during an interview on 11/03/16 at 12:38 p.m. and confirmed the MDS was coded incorrectly and did not reflect Resident #26 as receiving Hospice services.",2020-04-01
3923,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,279,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility failed to develop a comprehensive care plan for three (3) of twenty-three (23) Stage 2 residents related to [MEDICAL CONDITION] (GI bleed), ,[MEDICAL CONDITION]. difficle (C. Diff), isolation for the [DIAGNOSES REDACTED], and dental care. Resident Identifiers: #147, #139, #37. Facility census 109. Findings include: a) Resident #147 1) [MEDICAL CONDITION] Record review for Resident #147, on 11/02/16 at 11:50 a.m., found a note dated 05/07/16 from an acute care facility. This note indicated the resident had occasional blood in her stool and she was on Xarelto (a blood thinner) due to a [MEDICAL CONDITION] embolism. The physician for Resident #147 wrote in the admission history and physical, recent GI bleed. diagnosed with [REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 05/30/16 was reviewed on 11/02/16 at 12:57 p.m. for Resident #147. This MDS revealed the resident had the [DIAGNOSES REDACTED]. A review of the physician order [REDACTED]. A review of a lab test, complete blood count (CBC), for Resident #147 on 05/30/16 revealed the following results: --[NAME] blood count (WBC) was 13.5 (high); --Hemoglobin (HGB) level of 11.3 (low) with normal noted as 12.0 -16.0 gram/deciliter; and --Hematocrit (HCT) was 34.7 (low) with normal level noted as 37 - 47 percent. The HGB, and HCT is an indicator of [MEDICAL CONDITION] (too few red blood cells). Written on the lab test result was a note stating (typed as written), active GI (gastrointestinal) bleed, loose bm's (bowel movement) with sticky clay color noted. not black, but red visible blood with clots. Resident #147 had a progress note on 06/08/16 revealing a new order to obtain a CBC in the morning. Written on the note said due to active GI bleed/ recent hospitalization . On 06/27/16 the resident was sent to the acute care facility for the GI bleed. 2) ,[MEDICAL CONDITION]. Difficle and contact isolation On 05/31/16 a progress note revealed a stool specimen was positive for ,[MEDICAL CONDITION]. difficle (C. Diff). The physician ordered the resident to start receiving [MEDICATION NAME] (used to treat bacterial infections) 500 milligrams (mg) by mouth for two (2) weeks. The resident continues to have several loose stools daily. The note revealed contact isolation was started. A progress note on 06/01/16 revealed the resident is having several loose stool this shift and the resident remains on [MEDICATION NAME] without any adverse effect. A progress note, dated 06/03/16, revealed the resident continues to take [MEDICATION NAME] for [DIAGNOSES REDACTED]. A note, dated 06/07/16, indicated Resident #147 had a [MEDICATION NAME] appointment scheduled for 06/16/16 to follow up with recent GI bleed as resident persists to have visible blood in stools. A review Resident #147's comprehensive care plan, on 11/02/16 at 2:10 p.m., found no care plan related to the GI bleed, [DIAGNOSES REDACTED], and the contact isolation. In an interview with licensed practical nurses (LPN) #43 and #58, on 11/02/16 at 5:02 p.m., found they reviewed the care plan for Resident #147, and they both confirmed the comprehensive care plans did not address the needed care areas of GI bleed, [DIAGNOSES REDACTED], and the contact isolation. b) Resident #37 During a Stage1 interview and observation, on 10/31/16 at 2:24 p.m., revealed Resident #37 had missing teeth. Resident #37 voiced problems and stated she needed several teeth removed. The resident related she had asked to go to the dentist, and had a broken tooth which caused pain. Resident #37 said she needed an appointment for extraction of five (5) teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 08/29/16 noted Resident #37 had an obvious or likely cavity or broken natural teeth. Section V indicated a care plan would be developed. Further review of the medical record, on 11/02/16 revealed no evidence a care plan had been developed related to dental care needs. c) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order for [REDACTED]. The care plan, revised on 09/11/16, reviewed on 11/02/16 at 9:38 a.m., was silent for a care plan related to dental care. During a medical record review, with Licensed Practical Nurse (LPN) #33, she related she was not sure where to look. The interim director of nursing reviewed the care plan, including resolved issues and stated a care plan had not been developed related to dental/oral health.",2020-04-01
3924,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,280,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan for one (1) of twenty-three (23) Stage 2 residents reviewed during the annual quality indicator survey. Resident #143's care plan did not identify a decline in urinary incontinence after hospitalization . Resident identifier: #143. Facility Census: 109. Findings include: a) Resident #143 Review of the medical record on 11/03/16 at 9:51 a.m., revealed Resident #143 was admitted to the facility on [DATE]. The three-day continence management diary initiated on 06/29/16 noted Resident #143 was incontinent three (3) out of twenty-eight (28) checks on 07/01/16, 07/02/16, and 07/06/16. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/04/16 noted the resident was always continent of urine under section H0300. Resident #143 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The activity of daily living forms dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) identify Resident #143 as always incontinent of urine since 07/22/16. The quarterly MDS with an ARD of 10/03/16 noted the resident was always incontinent of urine and indicated a toileting program was not attempted. The Clinical Records Coordinator (CRC) #93 reviewed the records during an interview on 11/03/16 at 12:11 p.m. and confirmed Resident #143 was initially occasionally incontinent of urine and is now always incontinent. CRC #93 reviewed the current care plan and acknowledged the care plan lacked a focus, goal or any interventions for urinary incontinence. Nurse Aide (NA) #75 confirmed Resident #143 is always incontinent of urine during an interview on 11/03/16 at 1:42 p.m.",2020-04-01
3925,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,309,E,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow physician orders for three (3) of twenty-three (23) Stage 2 residents. The facility failed to follow a physician order for [REDACTED]. Resident Identifiers: #40, #136, and #139. Facility census 109. Findings include: a) Resident #40 Review of Resident #40's pharmacy consultant report dated 09/20/16 was reviewed on 11/03/16 at 12:30 p.m., revealed the resident received Quetiapine ([MEDICATION NAME]) 50 milligram (mg) daily for behavioral or psychological symptoms of dementia since 03/24/16 and [MEDICATION NAME] (Klonopin) 0.5 mg twice a day. The consultant report indicated both were due for a gradual dose reduction (GDR). The pharmacy consultant made the recommendation for a GDR of the resident's Quetiapine 50 mg to 25 mg at night with the end goal of discontinuation of the medication. If medication is to continue at this dose, the prescriber must document a clinical contraindication, defined as a patient-specific rational including, 1) documentation that a target symptom(s) returned or worsened during a dose reduction attempted during the most recent facility admission, and 2) why additional attempted dose reduction would be likely to impair the resident's function or increase distressed behavior. The physician accepted the recommendations with the following modifications to reduce [MEDICATION NAME] to 0.25 mg in the morning, and 0.5 mg in the evening. The physician signed the recommendations on 10/04/16. A review of Resident #40's physician orders on 11/03/16 at 12:35 p.m., found a physician order was written on 10/04/16 for the GDR for the [MEDICATION NAME], but no physician order was written for the Quetiapine. A review of Resident #40's Medication Administration Record [REDACTED]. From 10/10/16 through 10/31/16 there was no documentation the resident received the medication at all. A review of the Resident #40's physician order for [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 11/03/16 at 12:57 p.m., Resident #40's the pharmacist consultant report, the physician orders, (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. The LPN said she could not find anywhere in the record where the physician wrote in the resident's record contraindication the resident should not have the GDR. b) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order for [REDACTED]. The physician services nursing facility subsequent visit form, dated 03/08/16, noted the chief complaint/history record many damaged and non-restorable teeth. A physician's order dated 04/12/16, recorded it was, Ok for dental consult due to clenching mouth when eating. The assessment/plan included a referral to an oral surgeon for a full mouth extraction per the dentist due to, many damaged and non-restorable teeth, and was noted on 04/25/16. The medical record, reviewed from date of admission through 11/03/16 found a progress note dated 04/25/16 which indicated the dentist assessed Resident #139 and the facility received an order to refer the resident to an oral surgeon for full mouth extraction. Further record review found the following notes: --04/28/16 - the resident saw the dentist and a recommendation was made to do a full mouth extraction; --04/30/16 - spoon feed all meals; --05/05/16 - waiting for an appointment for full mouth extraction; --06/30/16 - continue on [MEDICATION NAME] for mouth, resident is very hard to feed meals due to continually closing mouth; --07/07/16 - continue [MEDICATION NAME] to gums of mouth provided, when resident eating lunch because staff noticed resident crunching teeth, face getting red, and nurse provided with pain meds (medication) [MEDICATION NAME] 0.25 (milliliters) via mouth; --08/16/12 - a care plan meeting note was silent to dental issues. The family attended the meeting; and --09/07/16 - weight warning of a five percent (5%) weight loss over 30 days. No evidence was present in the electronic medical record or the paper record to indicate Resident #139 had received the consult with an oral surgeon. During an interview with Social Worker (SW) #54, on 11/02/16 at 11:06 a.m., the SW verbalized she had attended Resident #139's care plan meeting. The SW said the responsible party attended the meeting. When asked what was discussed with the family member, the social worker did not mention dental care. Upon inquiry, SW #54 said no evidence was present to indicate the facility had discussed the physician's order for a consult with the oral surgeon with the family, or that the family had denied the consult. The SW said the facility was looking for documentation. Scheduler #127, interviewed on 11/02/16 at 11:30 a.m., stated no evidence was present to indicate an appointment had been scheduled for the consult with the oral surgeon. A follow-up interview with the interim director of nursing (IDON) on 11/03/16 at 3:30 p.m. confirmed the facility failed to follow the physician's order to obtain a surgical consultation. c) Resident #136 A medical record review, on 11/01/16, indicated Resident #136 received [MEDICATION NAME] ten (10) milligrams (mg) by mouth daily for major [MEDICAL CONDITION] - single episode and [MEDICATION NAME] 1 mg by mouth daily for dementia with behavioral disturbance. Further review, revealed the resident had a witnessed fall on 10/16/16, losing his balance and falling backwards. A pharmacy recommendation, reviewed on 11/03/16 at 10:30 a.m., noted a recommendation for a gradual dose reduction of [MEDICATION NAME]. The physician's response noted, Not my patient, Need consult. The admission history and physical from the hospital had recorded the resident had been admitted to the hospital due to increased confusion and marked agitation including throwing things and striking out at people. It noted he had baseline mental [MEDICAL CONDITION] with very poor hearing and vision and inability to express himself. Scheduler #127, interviewed at 11:30 a.m., said no information was present to indicate the appointment had been scheduled. At 1:10 p.m. on 11/03/16, the interim director of nursing (DON) reviewed the medical record, and said the psychiatrist visited residents at the facility about every two (2) weeks. She reviewed the medical record and confirmed the order had not been discontinued. The interim DON searched for a consult, said she was unable to find evidence it had been completed, and confirmed the facility failed to carry out the physician's order.",2020-04-01
3926,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,315,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents incontinent of bladder receives the appropriate treatment and services to restore normal bladder function to the extent possible. Resident #143's increase in urinary incontinence was not assessed after each admission and interventions were not put into place to address the decline in bladder control. Resident identifier: #143. Facility census: 109. Findings include: a) Resident #143 Review of the medical record on 11/03/16 at 9:51 a.m., revealed Resident #143 was initially admitted to the facility on [DATE]. She was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Resident #143 returned to the hospital on [DATE] and was readmitted to the facility on [DATE]. The three-day continence management diary initiated on 06/29/16 noted Resident #143 was incontinent three (3) out of twenty-eight (28) checks on 07/01/16, 07/02/16, and 07/06/16. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/04/16 noted the resident was always continent of urine under section H0300. The activity of daily living forms dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) identified Resident #143 as always incontinent of urine since 07/22/16. The quarterly MDS with an ARD of 10/03/16 noted the resident as always incontinent of urine and is marked No under section H0200 indicating a toileting program was not attempted. The medical record was silent in regards to any toileting assessments. The Clinical Records Coordinator (CRC) #93 reviewed the records during an interview on 11/03/16 at 12:11 p.m., confirmed Resident #143 was initially occasionally incontinent of urine and is now always incontinent. She acknowledged the urinary incontinence was not identified during Resident #143's recent quarterly assessment and a plan was not put into place to address this concern. CRC #93 stated it is the restorative nurse's job to conduct the three-day continence management diaries on the residents. Licensed practical nurse (LPN)/restorative nurse #146 presented Resident #143 ' s initial toileting assessment during an interview on 11/03/16 at 12:24 p.m. The form is titled Three-day Continence Management Diary and is completed by the nursing assistants. LPN #146 acknowledged she was not familiar with Resident #143 and reported there were no urinary incontinence assessments completed after readmissions on 07/18/16 and 08/08/16. LPN #146 stated she does not participate in the residents care conferences and is notified when an assessment needs to be completed. During an interview at 2:05 p.m. on 11/03/2016, the Assistant Director of Nursing (ADON) confirmed a three day continent assessment should have been done on Resident #143 after each admission.",2020-04-01
3927,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,371,F,0,1,VTNG11,"Based on observation, staff interviews and policy review, the facility failed to store and serve food in a safe and sanitary manner. Food in the cooler was exposed to air and undated, and food in the nourishment refrigerator rooms was unlabeled and undated. The staff were serving food with contaminated gloves, and touching food items with their bare hands. This has the potential to affect more than a limited number of residents. Facility census 109. Findings include: a) Cooler and nourishment room refrigerator 1. During the initial tour of the kitchen, on 10/31/16 at 11:50 a.m., with food service director, observation of the cooler found fourteen (14) large carrots open, undated and exposed to the air. The food service director acknowledge the need for the carrots to be covered and dated when they were open. Observed the cooler on 11/02/16 at 2:00 p.m., found the fourteen (14) carrots continue to be open and exposed to air and undated. Observation of the cooler on 11/03/16 at 9:40 a.m., found fourteen (14) carrots continued to be opened and exposed to air and undated. 2. Observation and interview with clinical reimbursement coordinator (CRC) #93, on 11/02/16 at 4:45 p.m., found the (a) side of the nourishment room refrigerator with 21 slices of American cheese in a clear plastic zip lock bag, half a gallon (1/8th full) of two (2) percent milk (with a best used by date of 11/01/16), a plastic pitcher full of orange juice, another half a gallon of two (2) percent milk (3/4th full), and a half a gallon of Tru Moo milk (1/3rd full). These items were undated and/or unlabeled. The (b) side of the nourishment room refrigerator was observed with CRC #93, on 11/02/16 at 4:49 p.m., with a half a gallon of 2% milk (1/2 full was open and undated). During the two (2) observations of the nourishment refrigerator with CRC #93, she confirmed someone should have thrown away the milk that was already passed the used by date, and put the date they opened the other milk. The CRC said the orange juice should have had a date on the top when it was put in the refrigerator and the cheese should have had a label and a use by date on the bag. A review of the facility's refrigerated/ frozen storage policy, on 11/03/16 at 3:00 p.m., revealed all food is to be labeled with the name of the product and the date received and use by date once opened. b) Handling food 1. During a dining observation of the Coral dining room, on 11/01/16 from 12:04 p.m. through 12:45 p.m., Nurse Aide (NA) #90 touched bread with bare hands. The NA lifted the top slice of bread, exposing the filling beneath, asked the resident if she wanted lettuce or tomato, placed it back on the sandwich, lifted it again and placed items on the sandwich. The NA held the bread in place with her fingers, while cutting the sandwich in half, then served it to Resident #73. Nurse Aide (NA) #135, also touched bread with bare hands while serving a sandwich to Resident #67. An interview with Nurse Practice Educator (NPE) #38, on 11/02/16 at 1:06 p.m., confirmed staff should not have touched food items with bare hands and related facility practice required staff utilize gloves if touching food items. 3. On 11/01/2016 at 11:59 p.m. observation revealed Dietary Cook #42 wearing gloves handling meal slips. The employee opened bun bags and prepared fish sandwiches while wearing the contaminated gloves. Dietary Cook #42 proceeded to handle dispenser of aluminum foil and cover plates of food. The employee prepared additional sandwiches wearing the contaminated gloves. An additional observation in the presence of the Food Service Director revealed the employee removed buns from the bags and prepared fish sandwiches without changing contaminated gloves. The Food Service Director agreed the employee ' s gloves should have been changed. During an interview on 11/02/16 at 1:00 p.m., the Nurse Practice Educator stated upon orientation, staff are trained on proper food handling, but the kitchen will provide education regarding use of gloves when handling packaged items, serving foods and also holding glasses of beverages by the rims.",2020-04-01
3928,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,411,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure dental services were obtained for one (1) of three (3) residents reviewed. The facility failed to obtain a surgical consultation with an oral surgeon as directed by the dentist, for a resident who received Medicare services. Resident identifier: #139. Facility census: 109. Findings include: b) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order, dated 04/25/16, for a consult with an oral surgeon for extraction of teeth, as recommended by the dentist. The physician services nursing facility subsequent visit form, dated 03/08/16, had noted the chief complaint/history record many damaged and non-restorable teeth. A physician's orders [REDACTED]. The dentist' assessment/plan included a referral to an oral surgeon for a full mouth extraction due to many damaged and non-restorable teeth, and was noted on 04/25/16. The medical record, reviewed from date of admission through 11/03/16 revealed a progress note dated 04/25/16 which noted the dentist assessed Resident #139 and the facility received an order to refer the resident to an oral surgeon for full mouth extraction. --04/28/16 - the resident saw the dentist and a recommendation was made to do a full mouth extraction; --04/30/16 - spoon feed all meals; --05/05/16 - waiting for an appointment for full mouth extraction; --06/30/16 - continue on [MEDICATION NAME] for mouth, resident is very hard to feed meals due to continually closing mouth; --07/07/16 - continue [MEDICATION NAME] to gums of mouth provided, when resident eating lunch because staff noticed resident crunching teeth, face getting red, and nurse provided with pain meds (medication) [MEDICATION NAME] 0.25 (milliliters) via mouth; --08/16/12 - a care plan meeting note was silent to dental issues. The family attended the meeting; and --09/07/16 - weight warning of a five percent (5%) weight loss over 30 days. No evidence was present in the electronic medical record or the paper record to indicate Resident #139 had received the consult with an oral surgeon. Nurse Aide (NA) #135, interviewed on 11/02/16 at 9:07 a.m., stated Resident #139 had dental pain, and staff used sponges for oral care. Licensed Practical Nurse (LPN) #64, present during the interview, and said the resident received [MEDICATION NAME] to the gums and teeth before meals for comfort and was now eating better. During an interview with Social Worker (SW) #54, on 11/02/16 at 11:06 a.m., the SW verbalized she had attended Resident #139's care plan meeting. The SW said the responsible party attended the meeting. When asked what was discussed with the family member, the social worker did not mention dental care. Upon inquiry, SW #54 said no evidence was present to indicate the facility had discussed the physician's orders [REDACTED]. The SW said the facility was looking for documentation. The census record indicated Resident #139 received Medicare services at the time of the order on 04/27/16 through 05/16/16. Scheduler #127, interviewed on 11/02/16 at 11:30 a.m., stated no evidence was present to indicate an appointment had been scheduled for the consult with the oral surgeon. A follow-up interview with the interim director of nursing (IDON) on 11/03/16 at 3:30 p.m. confirmed the facility failed to follow the physician's orders [REDACTED]. A dining observation, on 11/02/16 at 12:31 p.m., revealed Resident #139 received foods via a cup. The food was puree and a metal spoon was present on the tray. Upon inquiry, NA #69 said she did not use the spoon because it hurt the resident's teeth and she would turn her head away. NA #67 agreed and said Resident #139 received something for pain prior to meals. The medical director, requested an interview on 11/02/16 at 2:13 p.m., and said she wanted to address questions about Resident #139. The physician related she did not think the resident was a surgical candidate for a dental extraction and would not have had surgery. After explaining the appointment was for a surgical consultation, not surgery, the physician related she did not know why the appointment had not been made. Speech Therapist (ST) #31, on 11/02/16 at 3:50 p.m., said the administrator had requested she answer questions regarding Resident #139's dental care, refusal to eat and grinding of teeth. The ST said she had worked with the resident on admission to the facility and had related the grinding to [DIAGNOSES REDACTED] (inability to perform purposeful movements as a result of brain damage), not dental pain. When asked why the resident received [MEDICATION NAME] to her gums and teeth prior to meals if she did not have dental pain, the ST said she was not aware the resident received medication, and related she had not worked with Resident #139 in the last four (4) months. The ST note, dated 03/08/16 through 04/04/16 noted Resident #139 presented with clenched jaw and dental grinding especially during attempts at oral intake. Close jaw impaired; open jaw with resistance - impaired and again noted clenched jaw with dental grinding throughout the evaluation. The evaluation did not address dental pain. A follow-up interview with the interim DON on 11/03/16 at 3:30 p.m. confirmed the order had not been discontinued, no evidence was present to indicate the surgery had been contraindicated, no evidence the family had denied the consult, and verified the facility failed to follow the physician's orders [REDACTED].",2020-04-01
3929,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,412,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure dental services were obtained for one (1) of three (3) residents reviewed. The facility failed to obtain a surgical consultation with an oral surgeon as directed by the dentist, for a resident who received Medicaid services. Facility census: 109. Resident identifier: #139. Findings include: b) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order, dated 04/25/16, for a consult with an oral surgeon for extraction of teeth, as recommended by the dentist. The physician services nursing facility subsequent visit form, dated 03/08/16, had noted the chief complaint/history record many damaged and non-restorable teeth. A physician's orders [REDACTED]. The dentist' assessment/plan included a referral to an oral surgeon for a full mouth extraction due to many damaged and non-restorable teeth, and was noted on 04/25/16. The medical record, reviewed from date of admission through 11/03/16 revealed a progress note dated 04/25/16 which noted the dentist assessed Resident #139 and the facility received an order to refer the resident to an oral surgeon for full mouth extraction. --04/28/16 - the resident saw the dentist and a recommendation was made to do a full mouth extraction; --04/30/16 - spoon feed all meals; --05/05/16 - waiting for an appointment for full mouth extraction; --06/30/16 - continue on [MEDICATION NAME] for mouth, resident is very hard to feed meals due to continually closing mouth; --07/07/16 - continue [MEDICATION NAME] to gums of mouth provided, when resident eating lunch because staff noticed resident crunching teeth, face getting red, and nurse provided with pain meds (medication) [MEDICATION NAME] 0.25 (milliliters) via mouth; --08/16/12 - a care plan meeting note was silent to dental issues. The family attended the meeting; and --09/07/16 - weight warning of a five percent (5%) weight loss over 30 days. No evidence was present in the electronic medical record or the paper record to indicate Resident #139 had received the consult with an oral surgeon. Nurse Aide (NA) #135, interviewed on 11/02/16 at 9:07 a.m., stated Resident #139 had dental pain, and staff used sponges for oral care. Licensed Practical Nurse (LPN) #64, present during the interview, and said the resident received [MEDICATION NAME] to the gums and teeth before meals for comfort and was now eating better. During an interview with Social Worker (SW) #54, on 11/02/16 at 11:06 a.m., the SW verbalized she had attended Resident #139's care plan meeting. The SW said the responsible party attended the meeting. When asked what was discussed with the family member, the social worker did not mention dental care. Upon inquiry, SW #54 said no evidence was present to indicate the facility had discussed the physician's orders [REDACTED]. The SW said the facility was looking for documentation. The census record indicated Resident #139 received Medicare services at the time of the order on 04/27/16 through 05/16/16. Scheduler #127, interviewed on 11/02/16 at 11:30 a.m., stated no evidence was present to indicate an appointment had been scheduled for the consult with the oral surgeon. A follow-up interview with the interim director of nursing (IDON) on 11/03/16 at 3:30 p.m. confirmed the facility failed to follow the physician's orders [REDACTED]. A dining observation, on 11/02/16 at 12:31 p.m., revealed Resident #139 received foods via a cup. The food was puree and a metal spoon was present on the tray. Upon inquiry, NA #69 said she did not use the spoon because it hurt the resident's teeth and she would turn her head away. NA #67 agreed and said Resident #139 received something for pain prior to meals. The medical director, requested an interview on 11/02/16 at 2:13 p.m., and said she wanted to address questions about Resident #139. The physician related she did not think the resident was a surgical candidate for a dental extraction and would not have had surgery. After explaining the appointment was for a surgical consultation, not surgery, the physician related she did not know why the appointment had not been made. Speech Therapist (ST) #31, on 11/02/16 at 3:50 p.m., said the administrator had requested she answer questions regarding Resident #139's dental care, refusal to eat and grinding of teeth. The ST said she had worked with the resident on admission to the facility and had related the grinding to [DIAGNOSES REDACTED] (inability to perform purposeful movements as a result of brain damage), not dental pain. When asked why the resident received [MEDICATION NAME] to her gums and teeth prior to meals if she did not have dental pain, the ST said she was not aware the resident received medication, and related she had not worked with Resident #139 in the last four (4) months. The ST note, dated 03/08/16 through 04/04/16 noted Resident #139 presented with clenched jaw and dental grinding especially during attempts at oral intake. Close jaw impaired; open jaw with resistance - impaired and again noted clenched jaw with dental grinding throughout the evaluation. The evaluation did not address dental pain. A follow-up interview with the interim DON on 11/03/16 at 3:30 p.m. confirmed the order had not been discontinued, no evidence was present to indicate the surgery had been contraindicated, no evidence the family had denied the consult, and verified the facility failed to follow the physician's orders [REDACTED].",2020-04-01
3930,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,428,E,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews the facility failed to ensure a pharmacist recommendation was acted upon by failing to ensure an order was written to implement the gradual dose reduction (GDR) for one (1) of five (5) Stage 2 residents for a GDR. Resident Identifiers: #40. Facility census 109. Findings include: a) Resident #40 Review of Resident #40's pharmacy consultant report dated 09/20/16 was reviewed on 11/03/16 at 12:30 p.m., revealed the resident received Quetiapine (Seroquel) 50 milligram (mg) daily for behavioral or psychological symptoms of dementia since 03/24/16 and Clonazepam (Klonopin) 0.5 mg twice a day. The consultant report indicated both were due for a gradual dose reduction (GDR). The pharmacy consultant made the recommendation for a GDR of the resident's Quetiapine 50 mg to 25 mg at night with the end goal of discontinuation of the medication. If medication is to continue at this dose, the prescriber must document a clinical contraindication, defined as a patient-specific rational including, 1) documentation that a target symptom(s) returned or worsened during a dose reduction attempted during the most recent facility admission, and 2) why additional attempted dose reduction would be likely to impair the resident's function or increase distressed behavior. The physician accepted the recommendations with the following modifications to reduce Clonazepam to 0.25 mg in the morning, and 0.5 mg in the evening. The physician signed the recommendations on 10/04/16. A review of Resident #40's physician orders on 11/03/16 at 12:35 p.m., found a physician order was written on 10/04/16 for the GDR for the Clonazepam, but no physician order was written for the Quetiapine. A review of Resident #40's Medication Administration Record [REDACTED]. From 10/10/16 through 10/31/16 there was no documentation the resident received the medication at all. A review of the Resident #40's physician order for [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 11/03/16 at 12:57 p.m., Resident #40's the pharmacist consultant report, the physician orders, (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. The LPN said she could not find anywhere in the record where the physician wrote in the resident's record contraindication the resident should not have the GDR.",2020-04-01
3931,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,441,F,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, medical record review and policy review, and Centers for Disease Control and Prevention guidelines, the facility failed to maintain an infection control program to prevent the spread of disease and infection to the extent possible. The facility failed to implement contact precautions for a resident with suspected shingles, soiled linens were handled improperly, and staff failed to utilize proper hand hygiene and/or personal protective equipment (PPE) when handling items contaminated with nasal secretions. This practice affected three (3) residents, but had the potential to affect all residents. Resident identifier: Resident #139, #97, and #57. Findings include: a) Resident #97 During a Stage 1 interview, on 10/31/16 at 3:18 p.m., Resident #97 voiced she had shingles, and pulled up her shirt exposing fluid filled blisters in large patches in a stripe across her abdomen from her left side to her right side. The resident said the areas were painful and she had eaten in her room that date due to the shingles. Shingles is caused by the reactivation of the [MEDICATION NAME]-[MEDICATION NAME] virus (VZV), the same virus that causes chicken pox. Observation revealed no signage on the door or personal protective equipment (PPE) such as gowns, masks, disposable vital signs equipment upon entry of the room. Upon inquiry, Nurse Aide (NA) #22, said the resident required no special precautions. Immediately after the resident interview, during a conversation with Licensed Practical Nurse (LPN) #64 she said the resident did not require precautions because she did not yet have a diagnosis. The nurse said the physician wanted to wait and see if it was a rash. The nurse said staff were using gloves, washing hand and the resident was staying in her room. When asked how long the resident had the areas, the nurse said they were found during the resident's shower on 10/30/16. When asked about the resident's roommate and the roommate's visitors, the nurse related the facility had not considered that factor, and agreed there was a potential for transmission of disease and infection. Another observation, on 11/01/16 at 8:43 a.m., revealed signage on the door and personal protective equipment at the doorway. During a conversation 2:05 p.m., the medical director said the facility had notified her about the shingles after LPN #64's conversation with the surveyor on 10/31/16, said the attending physician should have been contacted and contact precautions were now in place. Nurse Practice Educator (NPE) #88, interviewed on 11/02/16 at 3:15 p.m., said Resident #97 had shingles and was placed in isolation on 11/01/16. The NPE said the resident had the rash, but the physician did not diagnose it as shingles, although he was treating it with medication. She said he did not order isolation. Upon inquiry, the NPE stated she could place a resident in isolation if they were symptomatic or presented with a suspected illness warranting isolation and then notify the physician for an isolation order. The NPE said that in hind sight she should have placed Resident #97 in isolation and phoned the physician for an order. She further added she was not aware that signage and personal protective equipment were not in place initially, but were in place now. physician's orders [REDACTED]. b) Resident #139 A random observation, on 11/02/16 at 9:13 a.m., revealed secretions draining from Resident #39's nasal passages. The clear mucous secretions were draining down and across the resident's mouth and dangling from the chin. Licensed Practical Nurse (LPN) #64, donned gloves and cleaned the resident's face with washcloths and towels. Upon completion, the items were placed on the resident's over-the-bed table where food items were placed. LPN #64 requested Nurse Aide (NA) #135 dispose of the items. The NA picked up the soiled items with bare hands, placed them in a plastic bag, exited the room without performing hand hygiene, carried the items to the soiled utility room, exited the room without utilizing hand hygiene and started down the hallway. NA #135, interviewed immediately after, said she should have worn gloves when picking up the soiled items, did not know the items contained nasal secretions. She also voiced she should have washed her hands. The NA acknowledged the practice created the potential for cross-contamination. c) Resident #57 During a random observation, on 11/02/16 at 12:43 p.m., Nurse Aide (NA) #110 placed soiled linens on the sink. With ungloved hands, the NA placed the linens in a plastic bag, then washed her hands and exited the room. Upon inquiry, the nurse aide said the soiled linens should not have been placed on the sink, but the resident was really dirty and she wanted to get her changed. The NA indicated the facility practice required the linens be placed in a bag. An interview with Nurse Practice Educator (NPE), on 11/02/16 at 3:30 p.m., confirmed the facility practice required staff to utilize gloves when handling soiled linens containing body fluids/secretions and required personal protective equipment when performing tasks which created a potential for cross contamination. The NPE said staff should have performed hand hygiene after performing tasks in the resident's rooms and after handling soiled linens. The Linen Handling Policy, reviewed on 11/02/16 noted all linen would be handled, stored, transported, and processed to contain and minimize exposure to waste products. All linen would be handled the same, using Standard Precautions, to provide effective containment and potential for cross-contamination from soiled linen. The policy directed staff to place soiled linen directly in a covered container at the location where removing the linen. Further guidance indicated staff would remove gloves, wash after handling soiled linen and before transporting bagged linen. Centers for Disease Control guidelines noted people with active lesions caused by herpes [MEDICATION NAME] can spread VZV to susceptible people who have not had [MEDICATION NAME] and never received chicken pox vaccine. The lesions are infectious until they dry and crust over and people with active herpes [MEDICATION NAME] lesions should avoid contact with susceptible people until the lesions dry and are crusted.",2020-04-01
3932,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,490,F,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, staff interview, medical record review, resident interview and policy review, the facility was not administered in a manner which utilized its resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident. The administration failed to ensure the safety of residents after an allegation of sexual abuse, failed to ensure allegations of abuse were thoroughly investigated and/or reported to the appropriate State agencies, failed to ensure the provision of medically related social services, and failed to ensure criminal background checks were completed as required. This practice affected one (1) of one (1) resident reviewed for abuse, and had the potential to affect all residents. Resident identifier: Resident #164. Employee Identifier: Nurse Aide (NA) #20. Findings include: a) Criminal background checks During a personnel record review related to criminal background checks, with the Human Resources Regional Director (HRRD) #150, on 11/02/16 at 2:30 p.m., the director provided a copy of a State police background check, dated 12/07/15 for Nurse Aide (NA) #20, who was hired on 11/19/15. Upon inquiry, the director related no information was present to indicate the facility had entered the NA into the West Virginia (WV) Cares system. The administrator, interviewed at 2:40 p.m., said the WV Cares form was completed on paper on 11/11/15 and submitted, and was informed at a later time that he had to submit it electronically. The administrator provided a copy of the bill from Morphotrust, which noted a payment in the amount required for only a State background check. He confirmed a federal background check had not been completed. The SAFRAN MorphoTrust USA guideline, with a revision date of Sept (YEAR) (September (YEAR)) was currently doing the fingerprinting for WV CARES for both a West Virginia (WV) and Federal Bureau of Investigation (FBI) background check. Communications between MorphoTrust and WV Cares, dated 11/02/16, noted WV CARES won't (will not) have the result. WV Cares was not the agency of record, nor was a FBI (Federal Bureau of Investigation) check done. If the applicant needs processed under WV CARES, she will need to be printed again either in one of our live scan locations or we will need to get another set of fingerprint cards with the agency noted as WV CARES. We do not keep cards after 90 days, so our card scan team does not have anything to research. The time card, reviewed on 11/03/16 indicated Employee #20 had worked at the facility as recently as 11/01/16, and the other number of days for August, (MONTH) and (MONTH) of (YEAR): --October (YEAR) the NA worked twenty-three (23) of thirty-one (31) days; --September (YEAR) the NA worked twenty-one (21) of thirty (30) days; and --August (YEAR) the NA worked twenty-two (22) of thirty-one (31) days. The administrator acknowledged, during an interview on 11/03/16, the facility did not follow-up to ensure Nurse Aide #20 had been entered into the WV-CARES system. b) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our general conversation and told me it was Resident name (Resident #79). Review of the facility grievances/concern forms on 11/02/16 at 10:45 a.m. revealed a form dated 10/31/16 concerning Resident #164. Documentation of the incident stated (typed as written): --Resident name (Resident #164) stated another resident (Resident initials of Resident #79) was attempting to grab her hand. She said she pulled her hand away. She said that she did not feel uncomfortable with the situation that it was no big deal. She said that (Resident initials of Resident #79) was a friend of her husband. Attached to the form was a statement by ST #31. Also attached was an interview statement of Resident #79 interviewed by the Nursing Home Administrator (NHA). The initial statement of the interview (typed as written) states; I spoke with (Resident #79) related to an alleged advance that he may have made on a female resident. During an interview with Social Services Director (SSD) #54 on 11/03/2016 at 8:22 a.m., she commented, the other resident (Resident #79) had been a friend of her husband and was grabbing for her hand. The SSD #54 said she informed the Director of Nursing (DON) and completed a grievance/concern form. She reported the resident did not seem uncomfortable, nor did she expand about the incident. Upon further inquiry SSD #54 stated, Since she (Resident #164) just said he grabbed my hand, I didn't ask her to expand on the situation. Sometimes when people know each other they will sometimes just grab your hands as a greeting, so I assumed that was all it was. When asked if SSD #54 used the word abuse during the resident interview was the word abuse used, the SSD #54 stated, No I just used the word unsafe because sometimes the word abuse will upset a resident, but I will interview her again. Maybe I didn't ask enough questions and ask her to explain more the first time. Upon further inquiry after reviewing the Grievance/Concern form, she did not reply when asked if it should have been investigated as an allegation of sexual abuse. SSD #54 stated, If she would have felt unsafe or uncomfortable about the incident I would have reported it. She did not reply when asked again if this allegation should have been investigated and reported as an alleged abuse allegation. She did state, The investigation is not complete yet because we just received it on Monday and no interventions have been put into place because it was just a concern nor was it seen as an incident or reported to any state agencies. Resident #164 commented tearfully during a follow-up interview with on 11/03/2016 at 9:06 a.m., that the Social Worker had just been in her room. The Resident stated, I told her the same thing I told you yesterday (11/01/16) and the same thing I had told her on Monday (10/31/16), that Resident name (Resident #79) grabbed my arm to pull my hand down toward his private area. I didn't tell you his name yesterday though because I didn't think you would know who he was, but I had told her (SSD #54) his name. His (Resident #79) room is down here somewhere and every time he goes past my room, he (Resident #79) just stares at me. Resident #164 was tearful and visibly upset during the interview stating, They just don't want to believe things like this happen here and how upsetting it is for this to happen to a person. SSD #54 reported on 11/03/2016 at 9:19 a.m., that she had spoken with Resident #164 and she (Resident #164) had stated, the male resident had grabbed her hands and she motioned toward down. SSD #54 commented she would talk with the NHA and report this issue now as an allegation of sexual abuse. She explained the process that each morning the incidents/accidents and grievances/concerns are reviewed in the department meetings and after reviewing these determine whether to report any allegations. The SSD #54 stated, Maybe I should have asked more questions on Monday (10/31/16) of the resident and completed a better investigation. Review of the medical record on 11/03/16 at 9:36 a.m. revealed Resident #164 was admitted in (MONTH) (YEAR), her [DIAGNOSES REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/28/16 showed a brief interview for mental status (BIMS) score of 13, indicating the resident has intact cognitive function. Resident #164 has the capacity to make medical decisions as documented by her attending Physician on admission to the facility. The NHA reported during an interview on 11/03/16 at 10:00 a.m., We are currently in the process of reporting the alleged sexual abuse to the appropriate state agencies. He agreed the facility did not identify the allegation as sexual harassment or abuse, report to the appropriate State agencies and investigate appropriately. Employees are educated annually to recognize and report abuse and neglect. Upon inquiry as to why the allegation was not reported when it was discovered, he stated, We went with the interview information that we had, but I did not realize it was insufficient. He did not reply when inquired as to why the verbiage advances was used in his interview with Resident #79, but not treated as an allegation of sexual harassment and/or abuse. A review of the facility Abuse Prohibition Policy and Procedure for the included the following: --Identification of possible incidents or allegations which need investigation. --Investigation of incidents and allegations. --Protection of patients during investigations. --Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Upon receiving information concerning a report of suspected or alleged abuse, neglect report to appropriate State agencies. --Conduct an immediate and thorough investigation that focuses on whether abuse or neglect occurred and to what extent.",2020-04-01
3933,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,510,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain a physician's order [REDACTED]. Resident identifier: Resident #136. Facility census: 109. Findings include: a) Resident #136 A medical record review, on 11/03/16, revealed a radiology report dated 10/17/16. The report indicated Resident #136 had an x-ray of the left shoulder and ribs. Further review of the electronic and paper medical record revealed no evidence of a physician's orders [REDACTED].>The interim director of nursing, interviewed at 3:30 p.m., reviewed the medical record and confirmed she was unable to find a physician's orders [REDACTED].",2020-04-01
3934,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,513,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure x-rays and/or diagnostic reports were signed and dated for two (2) of twenty-two (22) Stage 2 residents. Resident identifiers: Resident #37 and #136. Facility census: 109. Findings include: a) Resident #37 and #136 A medical record review on 11/03/16, revealed chest X-ray reports for Resident #37 dated 08/19/16 and 08/10/16 which had not been signed by the physician. A laboratory report dated 10/10/16 for a hemoglobin A1c lab, basic metabolic panel, complete blood count with differential, and [MEDICAL CONDITION] stimulating hormone had not been signed by the physician. Another laboratory report, dated 08/19/16 for laboratory work which included an hepatic function panel and complete blood count did not have a physician's signature. The medical record for Resident #136, reviewed on 11/03/16, contained X-ray reports of the left shoulder and ribs dated 08/02/16 and 10/17/16. The reports did not contain a physician's signature. The assistant director of nursing (ADON), interviewed at 3:30 p.m., confirmed the reports had been flagged for the physician, but had not yet been signed. Upon inquiry, the ADON stated the physician was in the building frequently.",2020-04-01
3935,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,514,E,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to complete and accurately document in the medical record for four (4) of twenty- six (26) residents related to what behavior symptom(s) the staff is to monitor on the behavior monitoring forms, incomplete and inaccurate documentation for meal/fluid percentages, bedtime snack, and facility did not fill out a liability notice correctly. This had the potential to affect a limited number of residents. Resident identifiers: #40, #37, #150 and #68. Facility census 109. Findings include: a) Resident #40. A review of the (MONTH) (YEAR) behavior monitoring and intervention form, on 11/03/16 at 1:00 p.m., for Resident #40, found there was no behavior symptoms on the form in order for the staff to know what behaviors they are to be monitoring. The form revealed the resident is on [MEDICATION NAME] and [MEDICATION NAME]. The medication Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) has a marked through the name. A review of Resident #40's physician order [REDACTED]. A review of the psychotherapeutic medication use evaluation form dated 10/04/16, revealed Resident #40 had behaviors of grabbing, repetition, and refusing care. On 11/03/16 at 1:34 p.m., Resident #40's behavior monitoring and intervention form was reviewed by employee #35 licensed practical nurse (LPN), and she confirmed the staff should have written the resident's behavior on the (MONTH) (YEAR)'s form in order to know what behaviors to monitor. She said at one time it was hitting and grabbing, but the forms had changed to rejection of care, and grabbing. The LPN stated, I do not know why the [MEDICATION NAME] was marked through (resident's name) has been receiving the medication. b) Resident #40 A review of Resident #40's Medication Administration Record [REDACTED]. In an interview on 11/03/16 at 1:23 p.m. with licensed practical nurse (LPN) #35, she reviewed the (MONTH) (YEAR) MAR indicated [REDACTED]. The LPN said she did not know why the area are blank because the resident has been receiving the medication. c) Resident #150 During an interview on 11/02/16, the administrator indicated the facility had no demand bills in the past six (6) months for Resident #150. Liability notices, reviewed on 11/02/16 at 4:30 p.m., noted Resident #150 placed an X next to box A which stated, I want my bill for services I continue to receive submitted to the intermediary for a Medicare decision. You will be informed when the bill is submitted. If you do not receive a formal Notice of Medicare Determination within 90 days of this request you should contact: . The verification of receipt was signed by the resident and the Cost Reimbursement Coordinator (CRC) #11, on 07/26/16. During an interview with CRC #11 on 11/03/16 at 9:00 a.m., a request was made to the CRC to explain the form. The CRC said the resident had received notice due to she was discharging to home as a planned discharge and reviewed the medical record, and the resident had not requested an appeal. She said the resident had marked the wrong area on the form, and she had not noticed, and stated the form was inaccurate. d) Resident #37 During a Stage 1 interview on 10/31/16 at 2:05 p.m., Resident #37 said she did not receive the fluids she wanted between meals. Activity of daily living (ADL) records, reviewed on 11/02/16 at 3:07 p.m., revealed multiple omissions of data. Omissions included: October (YEAR): twelve (12) of ninety-three (93) opportunities --Breakfast: 10/31/16, 10/17/16, --Lunch: 10/31/16, 10/28/16, 10/25/16, 10/23/16, 10/17/16, 10/10/16, 10/09/16, 10/01/16 --Dinner: 10/27/16, 10/09/16 Omissions included eleven (11) of thirty-one (31) opportunities as follows: --Snacks: 10/30/16, 10/28/16, 10/27/16, 10/16/16, 10/14.16, 10/13/16, 10/09/16, 10/08/16, 10/07/16, 10/04/16, 10/02/16 September (YEAR): seventeen (17) of ninety (90) opportunities related to meal percent and fluid intake: --Breakfast: 09/30/16, 09/27/16, 09/08/16 --Lunch: 09/30/16, 09/27/16, 09/24/16, 09/15/16, 09/11/16, 09/08/16, 09/07/16 --Dinner: 09/27/16, 09/24/16, 09/21/16, 09/19/16, 09/09/16, 09/08/16, 09/06/16 Omissions included: fifteen (15) of thirty (30) opportunities as follows: --Snacks: 09/27/16, 09/24/16, 09/23/16, 09/22/16, 09/21/16, 09/201/6, 09/19/16, 09/18/16, 09/17/16, 09/14/16, 09/10/16, 09/09/16, 09/18/16, 09/07/16, 09/06/16, The director of nursing reviewed the medical record at 3:30 p.m. on 11/03/16, and confirmed the medical record was incomplete. e) Resident #68 On 10/31/16 at 12:45 p.m. in the Fiesta Dining Room (Dining room A), observed a refused meal for Resident #68. A resident seated at the table stated that Resident #68 waited over an hour for lunch, wasn't waiting any longer and left the dining room. During an interview on 10/31/16 at 12:48 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 did not eat lunch today. Review of Resident #68's medical record on 11/01/16 at 8:00 a.m., showed the activities of daily living (ADL) record dated 10/31/16 failed to reflect Resident #68's meal refusal. An observation on 11/01/16 at 12:20 p.m. showed Resident #68 ate a single ice cream cup and refused alternative food choices. Review of Resident #68's medical record on 11/02/16 at 8:30 a.m., showed the ADL record for meals, and dated 11/01/16 coded as 100% for lunch intake. During an interview on 11/01/16 at 12:25 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 sometimes ate one item, such as the ice cream that she ate for lunch today. In this case, CRC #93 states that Resident #68 will be recorded as eating 100% because the single ice cream cup is what the resident chose. During an interview on 11/02/16 at 11:05 a.m., the Director of Food Service states that they are told to divide the plate in quarters and if that ice cream cup is all a resident ate then it is documented as 25%.",2020-04-01
3936,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,520,F,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel records, resident and staff interviews, and policy review, the quality assessment and assurance (QAA) committee failed to identify and/or act upon a quality deficiency within the facility's operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The facility failed to ensure the safety of residents after an allegation of sexual abuse, failed to ensure allegations of abuse were thoroughly investigated and/or reported to the appropriate State agencies, failed to ensure the provision of medically related social services, and failed to ensure criminal background checks were completed as required. This practice affected one (1) of one (1) resident reviewed for abuse, and had the potential to affect all residents. Resident identifier: Resident #164. Employee Identifier: Nurse Aide (NA) #20. Findings include: a) Criminal background checks During a personnel record review related to criminal background checks, with the Human Resources Regional Director (HRRD) #150, on 11/02/16 at 2:30 p.m., the director provided a copy of a State police background check, dated 12/07/15 for Nurse Aide (NA) #20, who was hired on 11/19/15. Upon inquiry, the director related no information was present to indicate the facility had entered the NA into the West Virginia (WV) Cares system. The administrator, interviewed at 2:40 p.m., said the WV Cares form was completed on paper on 11/11/15 and submitted, and was informed at a later time that he had to submit it electronically. The administrator provided a copy of the bill from Morphotrust, which noted a payment in the amount required for only a State background check. He confirmed a federal background check had not been completed. The SAFRAN MorphoTrust USA guideline, with a revision date of Sept (YEAR) (September (YEAR)) was currently doing the fingerprinting for WV CARES for both a West Virginia (WV) and Federal Bureau of Investigation (FBI) background check. Communications between MorphoTrust and WV Cares, dated 11/02/16, noted WV CARES won't (will not) have the result. WV Cares was not the agency of record, nor was a FBI (Federal Bureau of Investigation) check done. If the applicant needs processed under WV CARES, she will need to be printed again either in one of our live scan locations or we will need to get another set of fingerprint cards with the agency noted as WV CARES. We do not keep cards after 90 days, so our card scan team does not have anything to research. The time card, reviewed on 11/03/16 indicated Employee #20 had worked at the facility as recently as 11/01/16, and the other number of days for August, (MONTH) and (MONTH) of (YEAR): --October (YEAR) the NA worked twenty-three (23) of thirty-one (31) days; --September (YEAR) the NA worked twenty-one (21) of thirty (30) days; and --August (YEAR) the NA worked twenty-two (22) of thirty-one (31) days. The administrator acknowledged, during an interview on 11/03/16, the facility did not follow-up to ensure Nurse Aide #20 had been entered into the WV-CARES system. b) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our general conversation and told me it was Resident name (Resident #79). Review of the facility grievances/concern forms on 11/02/16 at 10:45 a.m. revealed a form dated 10/31/16 concerning Resident #164. Documentation of the incident stated (typed as written): --Resident name (Resident #164) stated another resident (Resident initials of Resident #79) was attempting to grab her hand. She said she pulled her hand away. She said that she did not feel uncomfortable with the situation that it was no big deal. She said that (Resident initials of Resident #79) was a friend of her husband. Attached to the form was a statement by ST #31. Also attached was an interview statement of Resident #79 interviewed by the Nursing Home Administrator (NHA). The initial statement of the interview (typed as written) states; I spoke with (Resident #79) related to an alleged advance that he may have made on a female resident. During an interview with Social Services Director (SSD) #54 on 11/03/2016 at 8:22 a.m., she commented, the other resident (Resident #79) had been a friend of her husband and was grabbing for her hand. The SSD #54 said she informed the Director of Nursing (DON) and completed a grievance/concern form. She reported the resident did not seem uncomfortable, nor did she expand about the incident. Upon further inquiry SSD #54 stated, Since she (Resident #164) just said he grabbed my hand, I didn't ask her to expand on the situation. Sometimes when people know each other they will sometimes just grab your hands as a greeting, so I assumed that was all it was. When asked if SSD #54 used the word abuse during the resident interview was the word abuse used, the SSD #54 stated, No I just used the word unsafe because sometimes the word abuse will upset a resident, but I will interview her again. Maybe I didn't ask enough questions and ask her to explain more the first time. Upon further inquiry after reviewing the Grievance/Concern form, she did not reply when asked if it should have been investigated as an allegation of sexual abuse. SSD #54 stated, If she would have felt unsafe or uncomfortable about the incident I would have reported it. She did not reply when asked again if this allegation should have been investigated and reported as an alleged abuse allegation. She did state, The investigation is not complete yet because we just received it on Monday and no interventions have been put into place because it was just a concern nor was it seen as an incident or reported to any state agencies. Resident #164 commented tearfully during a follow-up interview with on 11/03/2016 at 9:06 a.m., that the Social Worker had just been in her room. The Resident stated, I told her the same thing I told you yesterday (11/01/16) and the same thing I had told her on Monday (10/31/16), that Resident name (Resident #79) grabbed my arm to pull my hand down toward his private area. I didn't tell you his name yesterday though because I didn't think you would know who he was, but I had told her (SSD #54) his name. His (Resident #79) room is down here somewhere and every time he goes past my room, he (Resident #79) just stares at me. Resident #164 was tearful and visibly upset during the interview stating, They just don't want to believe things like this happen here and how upsetting it is for this to happen to a person. SSD #54 reported on 11/03/2016 at 9:19 a.m., that she had spoken with Resident #164 and she (Resident #164) had stated, the male resident had grabbed her hands and she motioned toward down. SSD #54 commented she would talk with the NHA and report this issue now as an allegation of sexual abuse. She explained the process that each morning the incidents/accidents and grievances/concerns are reviewed in the department meetings and after reviewing these determine whether to report any allegations. The SSD #54 stated, Maybe I should have asked more questions on Monday (10/31/16) of the resident and completed a better investigation. Review of the medical record on 11/03/16 at 9:36 a.m. revealed Resident #164 was admitted in (MONTH) (YEAR), her [DIAGNOSES REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/28/16 showed a brief interview for mental status (BIMS) score of 13, indicating the resident has intact cognitive function. Resident #164 has the capacity to make medical decisions as documented by her attending Physician on admission to the facility. The NHA reported during an interview on 11/03/16 at 10:00 a.m., We are currently in the process of reporting the alleged sexual abuse to the appropriate state agencies. He agreed the facility did not identify the allegation as sexual harassment or abuse, report to the appropriate State agencies and investigate appropriately. Employees are educated annually to recognize and report abuse and neglect. Upon inquiry as to why the allegation was not reported when it was discovered, he stated, We went with the interview information that we had, but I did not realize it was insufficient. He did not reply when inquired as to why the verbiage advances was used in his interview with Resident #79, but not treated as an allegation of sexual harassment and/or abuse. A review of the facility Abuse Prohibition Policy and Procedure for the included the following: --Identification of possible incidents or allegations which need investigation. --Investigation of incidents and allegations. --Protection of patients during investigations. --Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Upon receiving information concerning a report of suspected or alleged abuse, neglect report to appropriate State agencies. --Conduct an immediate and thorough investigation that focuses on whether abuse or neglect occurred and to what extent.",2020-04-01
4133,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,157,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician when the medication [MEDICATION NAME] was held for one (1) of five (5) residents due to lethargy. R. This had the potential to affect a limited number of people. Resident Identifier: #32. Facility Census: 29. Findings Include: a) Resident #32 A review of Resident #32's medical record found a physicians order for [MEDICATION NAME] .5 milligrams (MG) twice daily beginning on 06/30/16. This order was in effect until 07/13/16 when it was discontinued. There were no parameters to hold the medication if the resident was sedated. On 07/13/16 the physician changed Resident #32's [MEDICATION NAME] order to .25 mg twice daily and gave the parameter to hold if sedated. A review of the Medication Administration Record [REDACTED] -- 07/03/16 - 8:00 p.m. dose and the reason for holding the medication noted as Lethargy -- 07/04/16 - 8:00 a.m. and 8:00 p.m. doses and the reason for holding the medication on both occasions was Lethargy -- 07/05/16 - 8:00 a.m. dose and the reason for holding the medication Lethargy -- 07/05/16 - 8:00 p.m. dose and reason for holding the medication was listed as Doctors order -- 07/06/15 - 8:00 a.m. dose and the reason for holding the medication was again Lethargy -- 07/06/16 - 8:00 p.m. dose and the reason for holding the medication was listed as Doctors order -- 07/07/16 - 8:00 a.m. and 8:00 p.m. doses and the reason for holding the medication on both occasions was Lethargy -- 07/08/15 - 8:00 a.m. dose and the reason for holding the medication was Lethargy -- 07/09/15 - 8:00 a.m. dose and the reason for holding the medication was Lethargy Further review of Resident #32's medical record found no evidence the physician was notified when this medication was held. The record contained no order to hold Resident #32's [MEDICATION NAME] until 07/13/16 when the doctor was in the facility and saw the resident and decreased his dose of [MEDICATION NAME] and added the parameter to hold the medication if Resident #32 was sedated. An interview with the DON at 4:36 p.m. on 11/03/16 confirmed his medication was held on the above mentioned dates. She indicated she was certain that the physician knew they were holding the medicine, but agreed it was not documented in his record until 07/13/16. She stated, (Name of Attending Physician) was out of town and (Name of another physician) was covering for him in his absence and he came up to the floor frequently and she knows they had to have told him they were holding the medication. She indicated that once he was started on that medication he just went to sleep for days and that is why they were not giving it to him.",2020-02-01
4134,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,160,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the personal funds for two (2) of 21 (twenty-one) residents (who have personal accounts managed by the facility) had the balance of their personal funds conveyed to the individual administering the resident's estate or probate jurisdiction within 30 days of death. Resident identifiers: #34 and #35. Facility census: 29 Findings include: a) Resident #34 Review of the resident's Fund Balance Account at 8:54 a.m. on [DATE], found Resident #34 was discharged from the facility on [DATE]. The resident's remaining balance was $34.26 in a checking account and $108.79 in a savings account. b) Resident #35 Review of the resident's, Fund Balance Account at 8:54 a.m. on [DATE], found Resident #35 was discharged from the facility on [DATE]. A balance of $23.75 remained in the personal account. c) Interview with Employee #15, the manager of the resident's personal funds At 9:00 a.m. on [DATE], Employee #15, verified both Residents #34 and #35 were deceased . She stated no one had qualified to settle the resident's estate and the facility had a waiting period of 60 days to release the funds to the state's unclaimed property. Employee #15 said the facility has to send out a due diligence letter that gives the responsible party 60 days to come forward. She verified the facility had not conveyed the resident's personal funds within 30 days of the resident's death.",2020-02-01
4135,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,174,D,0,1,JLJC11,"Based on resident interview, record review, and staff interview, the facility failed to ensure a resident's personal property was safe at the facility. This was true for (1) of three (3) residents reviewed for the care area of personal property during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #15. Facility census: 29. Findings Include: a) Resident #15 At 9:12 a.m. on 11/01/16, Resident #15 said she had some very expensive lotions for her face and body stolen from her room. The resident identified the name brand of these items and said they were only available at very expensive stores. She estimated the cost of the lotions was over $100.00. She said she had an anxiety attack when she found out the items were missing and it still upsets her to talk about it now. She added, I always heard when you come to the nursing home they take everything. The resident said she told staff about the missing item. Staff looked for the lotion but could not locate the items. The resident said, They said they would order me some new lotion, but they never did. At 12:30 p.m. on 11/02/16, the social worker, #31 was asked what happens when a resident reports missing items. She stated, we start looking for it and call the families if needed. We also keep a complaint book about it. SW #31 provided a copy of the following narrative, dated 05/12/16. (Typed as written.) SW was called upstairs to the nursing unit because resident (Name of resident) was having a panic attack per (name of registered nurse). SW went to resident's room where she was having trouble breathing and she said that three bottles of makeup that were missing that her daughter had gotten for her. Many staff were in resident's room looking for the makeup. SW called daughter and MPOA (medical power of attorney), (name of daughter) and she said that there were two small royal blue bottles of Artistic natural lotion and cleanser that she had gotten her as well as two small bottles of (name of manufacture) day and night cream. SW relayed this to the staff. One small bottle was found, overturned and empty on the roommates bed side table. The record noted, .Resident continued to be quite upset for over an hour . Attached to the report was a note the maintenance supervisor was going to check to see if the facility had any more locked boxes to place in the resident's room. Employee #31 was asked about the facility's policy for replacing missing items. She said, We could have done so, I will look. She stated the resident was offered another room but she refused at that time. At 8:15 a.m. on 11/03/16, the administrator said the daughter said she was going to take care of the missing items. She confirmed she had no written information to verify her statement. Normally, we would have purchased these items if the family wanted. The daughter would have needed to bring in the receipt. At 2:45 p.m. on 11/03/16, the resident said she never received a locked box but, One of the nurses just came in yesterday and asked me if I wanted a locked box to keep my stuff in. I told her it wouldn't do any good because they would just steal the box. The nurse offered me a lock for my night stand drawer and I told her that would be good. At 2:47 p.m. on 11/03/16, licensed practical nurse (LPN), #23 said she talked with maintenance and they were going to take care of the issue. At 8:40 a.m. on 11/04/16, a second SW, #42, said the resident never received a locked box because we thought the daughter was bringing one in for the resident. Further review of the resident's medical record found the resident has capacity to make medical decisions. Her brief interview for mental status (BIMS) score was 15 on the last quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/16. A score of 15 indicates the resident is cognitively intact.",2020-02-01
4136,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,223,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure one (1) of one (1) resident reviewed for abuse, was free from verbal abuse. Resident #8 had a documented allegation that a Health Service Worker (HSW) had yelled during care. Resident identifier: #8. Facility census: 29 Findings include: a) Resident #8 A review of the clinical record for Resident #8 at 2:00 p.m. on 11/02/16 revealed she was a [AGE] year old female. Her brief interview for mental status (BIMS) was 15; which indicates she was cognitively intact. She had been determined by a physician to have the capacity to make medical decisions. Additionally, a review of the nurse's notes found a note written by Employee #77, licensed practical nurse (LPN) on 10/05/16. This note read, At approximately 5 a.m., resident rang her call bell. When answered, she replied, Am I not allowed to take a bowel movement in there anymore and pointed to her bathroom. When asked what she meant, she stated that the HSW had screamed like a maniac because I had a bowel movement didn't you hear it? When this nurse answered, No, I did not hear anyone yelling, she got visibly upset and stated, Of course, you would take her side. The HSW was not heard yelling at her and the resident was upset because she said, And she had to clean my bottom, too. When it was explained that the HSW was only trying to help her, she got even more upset and staff left the room so as not to upset her further. Resident was checked on around 6:00 a.m., and she was sleeping in her bed, with the call bell in place. Interview with Resident #8, on 11/02/16 at 3:30 p.m., found when asked if anyone had abused her mentally, physically, verbally and sexually. She replied, Yes, the aides (HSW) verbally yell at me especially when I have accidents (bladder and/or bowel incontinence). On 11/02/16 at 4:15 p.m., an interview with the Director of Nursing (DON), found that she was not aware of this reported allegation of verbal abuse. She was aware LPN, #77 had told them the resident was upset with a HSW, but had not mentioned she had yelled at her. On 11/03/16 at 1:24 p.m., an interview with Social Worker (SW) #42, Social Worker, found she had spoken with Resident #8 on 10/05/16 at 1:43 p.m. She further stated, I did not report it to the appropriate State agencies due to I was unaware of the HSW yelling at the resident. Review of the abuse and neglect policy found the following: The resident has the right to be from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Our hospital will ensure that residents are not subjected to abuse by anyone, including, but not limited to, hospital staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.",2020-02-01
4137,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,225,E,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, policy review, and staff interview, the facility failed to ensure an allegation of verbal abuse, voiced by Resident #8, was reported to the appropriate State agencies and thoroughly investigated. Resident identifier: #8. Facility census: 29. Findings include: a) Resident #8 A review of the clinical record for Resident #8 at 2:00 p.m. on 11/02/16 revealed she was a [AGE] year old female. Her brief interview for mental status (BIMS) was 15; which indicates she was cognitively intact. She had been determined by a physician to have the capacity to make medical decisions. Additionally, a review of the nurse's notes found a note written by Employee #77, licensed practical nurse (LPN) on 10/05/16. This note read, At approximately 5 a.m., resident rang her call bell. When answered, she replied, Am I not allowed to take a bowel movement in there anymore and pointed to her bathroom. When asked what she meant, she stated that the HSW had screamed like a maniac because I had a bowel movement didn't you hear it? When this nurse answered, No, I did not hear anyone yelling, she got visibly upset and stated, Of course, you would take her side. The HSW was not heard yelling at her and the resident was upset because she said, And she had to clean my bottom, too. When it was explained that the HSW was only trying to help her, she got even more upset and staff left the room so as not to upset her further. Resident was checked on around 6:00 a.m., and she was sleeping in her bed, with the call bell in place. Interview with Resident #8, on 11/02/16 at 3:30 p.m., found when asked if anyone had abused her mentally, physically, verbally and sexually. She replied, Yes, the aides (HSW) verbally yell at me especially when I have accidents (bladder and/or bowel incontinence). On 11/02/16 at 4:15 p.m., an interview with the Director of Nursing (DON), found that she was not aware of this reported allegation of verbal abuse. She was aware LPN, #77 had told them the resident was upset with a HSW, but had not mentioned she had yelled at her. On 11/03/16 at 1:24 p.m., an interview with Social Worker (SW) #42, Social Worker, found she had spoken with Resident #8 on 10/05/16 at 1:43 p.m. She further stated, I did not report it to the appropriate State agencies due to I was unaware of the HSW yelling at the resident. Review of the abuse and neglect policy found the following: The resident has the right to be from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Our hospital will ensure that residents are not subjected to abuse by anyone, including, but not limited to, hospital staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Administrator confirmed on 11/03/16 at 3:00 p.m. the alleged allegation of verbal abuse voiced by Resident #8 was not reported and/or investigated as it should have been. b) Policy Review On 11/04/16 at 10:00 a.m., review of the abuse and neglect policy, revealed the chain of command was to report to the immediate supervisor, and the facility would take whatever measures were necessary to protect the victim. It indicated all employees working during the shift of allegation would be questioned individually. A form indicating the date, time reported, response and description of the abuse is to be related to the Resident Advocate, the SW. The Administrator and the SW are responsible for the investigation of the incident.",2020-02-01
4138,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,226,E,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on abuse/neglect policy review, medical record review, and staff interview, the facility failed to ensure the implementation of their policy for investigation and reporting of allegations of abuse / neglect for one (1) of one (1) resident reviewed for abuse. The facility did not ensure the safety of Resident #8 when she had voiced an allegation of verbal abuse. The allegation was not immediately reported as required by State and federal regulations. The facility did not complete a prompt and thorough investigation of the allegation of abuse. Resident identifiers: #8. Facility census: 29. Findings include: a) Resident #8 A review of the clinical record for Resident #8 at 2:00 p.m. on 11/02/16 revealed she was a [AGE] year old female. Her brief interview for mental status (BIMS) was 15; which indicates she was cognitively intact. She had been determined by a physician to have the capacity to make medical decisions. Additionally, a review of the nurse's notes found a note written by Employee #77, licensed practical nurse (LPN) on 10/05/16. This note read, At approximately 5 a.m., resident rang her call bell. When answered, she replied, Am I not allowed to take a bowel movement in there anymore and pointed to her bathroom. When asked what she meant, she stated that the HSW had screamed like a maniac because I had a bowel movement didn't you hear it? When this nurse answered, No, I did not hear anyone yelling, she got visibly upset and stated, Of course, you would take her side. The HSW was not heard yelling at her and the resident was upset because she said, And she had to clean my bottom, too. When it was explained that the HSW was only trying to help her, she got even more upset and staff left the room so as not to upset her further. Resident was checked on around 6:00 a.m., and she was sleeping in her bed, with the call bell in place. Interview with Resident #8, on 11/02/16 at 3:30 p.m., found when asked if anyone had abused her mentally, physically, verbally and sexually. She replied, Yes, the aides (HSW) verbally yell at me especially when I have accidents (bladder and/or bowel incontinence). On 11/02/16 at 4:15 p.m., an interview with the Director of Nursing (DON), found that she was not aware of this reported allegation of verbal abuse. She was aware LPN, #77 had told them the resident was upset with a HSW, but had not mentioned she had yelled at her. On 11/03/16 at 1:24 p.m., an interview with Social Worker (SW) #42, Social Worker, found she had spoken with Resident #8 on 10/05/16 at 1:43 p.m. She further stated, I did not report it to the appropriate State agencies due to I was unaware of the HSW yelling at the resident. b) Review of the facility's policy for Abuse, Neglect, dated 09/01/16, found the following information: -- Purpose To prevent abuse, neglect or exploitation of resident, to the extent possible and ensure proper investigation and reporting of suspected cases, in compliance with applicable state and federal regulations. -- Procedure . When abuse, mistreatment, exploitation or neglect is suspected, the person who suspects the abuse will immediately notify the Supervisor. Supervisor will notify the Social Worker (SW) or Administrator, who will complete an incident report immediately and initiate an investigation. In addition, appropriate state authorities will be immediately notified",2020-02-01
4139,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,241,D,0,1,JLJC11,"Based on observation and staff interview the facility failed to ensure that Resident #25 was treated with dignity and respect. Two health service workers (HSW) were engaged in an argument with each other in the hallway with raised voices about who was going to take a resident into the shower room. Resident #25 was sitting in the hallway by the two HSWs on a shower chair at the time of the argument. This was found as a result of a random opportunity of discovery. Resident Identifier: #25. Facility Census: 29. Findings include: a) Resident #25 While standing at the nurse ' s station on 11/01/16 at 10:30 a.m. the surveyor heard two (2) female voices speaking in a raised tone. The surveyor left the nurses station to see who was screaming at who and observed HSW #66 and HSW #64 engaged in an argument standing outside the shower room door. This was approximately 200 feet from the nurse ' s station. HSW #66 was overheard saying in a very loud tone, I am not trying to be your boss or anything but by the time you get (name of another resident) out of bed I will be done showering (Name of Resident #25). HSW #64 was observed blocking the entrance to the shower room with her body and an empty shower chair. Resident #25 was observed sitting beside the shower room in a shower chair with a sheet draped around her body during the course of this incident. When HSW #66 saw the surveyor she loudly stated, I am getting the nurse. She proceeded to the solarium where she had summonsed Licensed Practical Nurse (LPN) #68 from a meeting in the blue room. She again in a very loud tone stated, (name of HSW #64) was blocking the shower room and not letting me take name of Resident #25 into the shower room. HSW #64 then entered into the solarium and loudly stated, That is not what happened. At which time LPN #68 told them they needed to go somewhere else to have this discussion. An interview with LPN #68 at 10:37 a.m. on 11/01/16 confirmed that HSW #66 and HSW #64 were engaged in an argument in the hallway about which one of them could take their resident into the shower room. She indicated that HSW #66 came into the meeting and stated she needed a nurse and when she stepped out of the meeting they began telling her what happened in very loud tone in the solarium where other residents could over hear. She stated, I thought they were going to tell me something quietly. I did not know they were going to start yelling. She was then advised that they had also been yelling at each other at the shower room in front of Resident #25. She confirmed they should have not raised their voices toward each other especially in front of a resident. At 10:55 a.m. on 11/01/16 the Director of Nursing (DON) was advised of the above mentioned incident. She stated, They know better than that they will not be here tomorrow. An additional interview with the DON later in the afternoon confirmed she had told both HSWs that their services would no longer be needed at the facility. She stated, I emailed the agency and told them not to send them back. She indicated that in orientation they review with each employee that this is the Residents home and they should not raise their voice or talk to each other in a disrespectful manner in front of any resident.",2020-02-01
4140,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,248,E,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, and staff interview, the facility failed to ensure there was an acceptable amount of activities available in the evenings and on the weekends. This was true for four (4) of nine (9) residents interviewed during Stage 1 of the Quality Indicator Survey (QIS). Resident identifiers: #5, #11, #15, #28. Findings include: a) Resident #5 An interview with Resident #5 at 4:23 p.m. on 10/31/16 found she enjoyed the activities held during the weekdays. When asked if activities were available in the evenings and weekends, the resident answered, No. Resident #5 said the weekends were really, blaugh. b) Resident #15 Resident #15 was interviewed at 9:19 a.m. on 11/01/16. The resident stated the activities she attended were good but there was never much in the evenings or on the weekends. c) Resident #28 An interview with the resident at 1:05 p.m. on 10/31/16 found she did not believe there were many activities on the weekends or the evenings. She said she attended Catholic services before coming to the facility, but they don ' t have that on the weekends. The priest only comes occasionally. d) Resident #11 Resident #11 was interviewed at 10:04 a.m. on 11/01/16. When asked if there are activities on the weekends and the evenings, the resident replied, No, there are not many activities on the weekends or evenings. The resident enjoyed the activities that were available. Review of the activity calendars at 2:00 p.m. on 11/01/16, found the following information: June, (YEAR) activity calendar; Only one activity was listed as being held after 3:45 p.m. A visits from a community organization was scheduled at 6:30 p.m. on 06/09/16. July, (YEAR) activity calendar; Only one (1) activity was held after 3:45 p.m. for the month of July. A local organization was scheduled for an activity, listed as visits, on 07/14/16 at 6:30 p.m. August, (YEAR) activity calendar: Only one (1) activity was held after 3:45 p.m. The same local organization came to the facility on [DATE] for an activity listed as, visits. September, (YEAR) activity calendar; Only one (1) activity was held after 3:45 p.m. for the entire month. The same local organization was scheduled on 09/15/16 for an activity listed as, visits. October, (YEAR) activity calendar; The calendar reflected there were no activities occurring after 3:45 p.m., for the entire month. November, (YEAR) activity calendar; Only one (1) activity was listed after 3:45 p.m. The same local organization is scheduled to visit the facility at 6:30 p.m. on 11/10/16. The activity director (AD), #6, was interviewed at 3:41 p.m. on 11/01/16. She confirmed a local organization usually comes one Thursday per month as 6:30 p.m. This was the only activity scheduled after 4:00 p.m. She said that she does not work in the evenings and she rarely works on weekends. She said she had an assistant but she needed the help of the assistant for activities held during the day time hours. She verified both she and her assistant leave around 4:00 p.m. during the weekdays. She stated the assistant, works some evenings to assist with the evening meal but the assistant is working as a nursing aide. She verified Saturday activities consist of a local Baptist church that comes every Saturday at 1:15 p.m. A gospel singing group also comes one (1) Saturday per month. When asked about the activity, entitled Newspaper, that is scheduled for every Saturday of each month at 11:30 a.m., AD #6 said, That is an individual activity, the ones that get a newspaper read it on their own. Two (2) activities were scheduled for every Sunday on each calendar, Bible study at 1:30 p.m. and TV time-residents choice at 3:00 p.m. AD #6 verified TV was an activity consisting of turning on the facility's television in the lounge area at 3:00 p.m. Facility staff were in charge of completing this activity. At 3:30 p.m. on 11/02/16, the DON said the facility was working on coming up with evening activities.",2020-02-01
4141,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,272,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #32's significant change Minimum Data Set (MDS) was accurately completed to reflect his status in the area of prognosis. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #32. Facility Census: 29. Findings Include: a) Resident #32 A review of Resident #32's medical record found a significant change MDS with an assessment reference date (ARD) of 08/03/16. This MDS under section J1400 indicated Resident #32 had a condition or chronic disease that may result in a life expectancy of less than six (6) months. Resident #32's medical record contained no evidence that Resident #32 had less than six (6) months to live. During an interview with Registered Nurse (RN) MDS Coordinator #50, at 5:07 p.m. on 11/03/16, when asked why section J1400 was completed this way she stated, That's an error I will have to fix that. She stated Resident #32 has no terminal [DIAGNOSES REDACTED].",2020-02-01
4142,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,280,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to review and revise the care plan for one (1) of one (1) Stage 2 sample residents reviewed for hospice. The care plan was not revised after his hospice treatments were changed. Resident identifier: #14. Facility census: 29. Findings include: a) Resident #14 Record review found the resident received Hospice services. Review of the resident's current care plan, dated 08/18/15, found the following problem: Needs Hospice care due to terminal condition of Dementia. The goal associated with the problem was, Will be kept comfortable-pain free. Approaches associated with the problem included: --Hospice care program of (name of company providing Hospice) --Pain scale and assessment per facility protocol --Encourage visitors --Observe for and report abnormal weight loss, change in appetite, increased skin breakdown --Encourage socialization and activity daily --Listen to the resident and discuss any concern voices At 11:03 a.m. on 11/02/16, the Minimum Data Set (MDS) coordinator, #50, said the Hospice agency has a care plan in their book upstairs which details the resident's care. MDS Coordinator #50 verified the Hospice agency does not attend the facility care plans. At 5:47 p.m. on 11/02/16, MDS Coordinator #50 provided a copy of the Hospice care plan, dated 07/16/15. MDS Coordinator #50, verified this was the only care plan from the Hospice agency. Review of the Hospice care plan with MDS Coordinator #50, noted the resident was on the following medications: [REDACTED] --[MEDICATION NAME] 40 milligrams (mg's) every 12 hours, as needed, for [MEDICAL CONDITION]; --[MEDICATION NAME] 1 tablet every 4 hours or rectal, as needed, for restlessness/agitation, nausea/vomiting; --[MEDICATION NAME] 0.5 mg., every 4 hours, as needed, for anxiety; --[MEDICATION NAME] sulfate nebulizer, 2.5 mg/3ml every 4-6 hours as needed; --[MEDICATION NAME], 100 mg's, three times a day; and --Instant food thickener or powder, apply one packet to 8 ounces of fluid. Review of the current physician's orders [REDACTED].#50, found the resident had no current physician's orders [REDACTED]. The resident currently receives eye drops for [MEDICAL CONDITION] and [MEDICATION NAME] liquid for cough and congestion. The resident's only diet restriction was ground meats. MDS Coordinator #50, verified the Hospice care plan was not updated when the above medications and diet changed. According to the Quality Indicator Survey (QIS) pathway for Hospice services: When hospice services are involved, the facility and hospice are jointly responsible for developing a coordinated plan of care for the resident that guides both providers and is based upon their assessments and the resident's needs and goals. Evaluation and revision of the care plan is coordinated between hospice and the facility; Staff evaluate outcomes of the plan (the effect of care plan goals and interventions) on a timely basis; and Staff identify changes in the resident's condition that require revised goals and care approaches.",2020-02-01
4143,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,282,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation the facility failed to ensure that Resident #32's care plan regarding pain management was implemented and that Resident #14's care plan was implemented in regards to his therapeutic diet. Resident #32 was one (1) of four (4) residents reviewed for the care area of pain management. The concern with Resident #14 was a random opportunity for discovery during the observation of the noontime meal. Resident identifiers: #32 and #14. Facility census: 29 Findings include: a) Resident #32 A review of Resident #32's medical record found the following physicians orders: -- [MEDICATION NAME] 5/ [MEDICATION NAME] 325 milligrams (mg) (Brand name [MEDICATION NAME]) every eight (8) hours as needed for pain. This order had a start date of 06/08/16 and was a current order at the time of this review. -- [MEDICATION NAME] 500 mg (Brand Name Tylenol) every four hours as needed for pain. This order had a start date of 07/08/16 and was a current order at the time of this review. A review of Resident #32's care plan found the following problem, Risk for pain on movement related to history of back pain . The goal associated with this problem is, Will have relief of pain within 1 hour of interventions. The interventions associated with this problem included, Administer medications as ordered . observe for and report effectiveness or any adverse side effects . and Monitor Pain and report to MD if pain is unresolved within 1 hour or worsens. Review of the MAR from 06/08/16 through present found the following occasions when Resident #32 was administered Tylenol and/or [MEDICATION NAME] and prompt assessments of its effectiveness was not completed: For the administration of [MEDICATION NAME]: -- 06/16/16 administered at 8:08 a.m. the effectiveness was not assessed until 06/17/16 at 7:54 a.m. (23 hours and 46 minutes after administration). -- 06/17/16 administered at 8:24 a.m. the effectiveness was not assessed until 06/17/16 at 12:57 p.m. (4 hours and 33 minutes after administration). -- 06/20/16 administered at 8:20 p.m. the effectiveness was not assessed until 06/23/16 at 7:34 p.m. (2 days 23 hours and 14 minutes after administration). -- 06/21/16 administered at 4:10 p.m. the effectiveness was not assessed until 06/21/16 at 8:05 p.m. (3 hours and 55 minutes after administration). -- 06/22/16 administered at 8:47 p.m. the effectiveness was not assessed until 06/23/16 at 5:16 a.m. (8 hours and 29 minutes after administration). -- 06/24/16 administered at 5:31 p.m. the effectiveness was not assessed until 06/25/16 at 5:40 a.m. (12 hours and 9 minutes after administration). -- 06/26/16 administered at 12:32 a.m. the effectiveness was not assessed until 06/26/16 at 5:22 a.m. (4 hours and 50 minutes after administration). -- 08/03/16 administered at 2:32 p.m. the effectiveness was not assessed until 08/08/16 at 1:56 p.m. (4 days 23 hours and 24 minutes after administration). -- 08/10/16 administered at 11:31 a.m. the effectiveness was not assessed until 08/10/16 at 2:39 p.m. (3 hours and 08 minutes after administration). -- 08/23/16 administered at 7:04 p.m. the effectiveness was not assessed until 08/26/16 at 3:00 p.m. (2 days 19 hours and 56 minutes after administration). -- 08/24/16 administered at 9:02 p.m. the effectiveness was not assessed until 08/25/16 at 12:06 p.m. (15 hours and 4 minutes after administration). -- 09/14/16 administered at 5:45 a.m. the effectiveness was not assessed until 09/15/16 at 5:16 a.m. (23 hours and 31 minutes after administration). -- 09/25/16 administered at 5:36 a.m. the effectiveness was not assessed until 09/25/16 at 8:32 a.m. (2 hours and 56 minutes after administration). -- 10/11/16 administered at 2:15 a.m. the effectiveness was not assessed until 10/11/16 at 5:19 a.m. (3 hours and 7 minutes after administration). -- 10/13/16 administered at 5:36 a.m. the effectiveness was not assessed until 10/13/16 at 1:27 p.m. (7 hours and 51 minutes after administration). -- 10/20/16 administered at 8:28 a.m. the effectiveness was not assessed until 10/20/16 at 2:45 p.m. (6 hours and 17 minutes after administration). For the administration of Tylenol: -- 07/20/16 administered at 9:12 a.m. the effectiveness was not assessed until 07/20/16 at 1:23 p.m. (4 hours and 11 minutes after administration). -- 07/21/16 administered at 7:41 p.m. the effectiveness was not assessed until 07/26/16 at 5:46 a.m. (4 days 10 hours and 5 minutes after administration). -- 10/15/16 administered at 7:55 p.m. the effectiveness was not assessed until 10/16/16 at 6:27 a.m. (10 hours and 32 minutes after administration). During an interview with the DON at 2:32 p.m. on 11/02/16 she indicated the nurse should go back 30 minutes to one hour after giving a pain medication to evaluate for its effectiveness she was asked to review the MAR for Resident #32 and she agreed these assessments were not completed timely. During an additional interview with the DON at 8:35 a.m. on 11/04/2016, she confirmed the facility did not follow their policy in monitoring for the relief of pain within 30 minutes to one (1) hour after the administration of a pain medication. She indicated, she felt the nurses did monitor for effectiveness but their documentation is very poor and there is no way to know for sure when they monitored for the effectiveness or if it was effective or not. b) Resident #14 The resident's current care plan, dated 08/18/15, was reviewed at 10:00 a.m. on 11/03/16. The problem: Resident needs limited assistance with eating with one person, related to dementia. The goal associated with this problem is: Will maintain nutritional status as evaluated by consuming at least 75% of meals and maintaining weight within 5 pounds of admission weight. Approaches included: Diet as ordered-08/12/16. Mechanical soft diet with ground meat. Place food in separate bowls to enable him to find them easier. Observation of the first meal upon entrance to the facility, the noon meal at 12:39 p.m. on 10/31/16, found the resident was seated in the lounge area near the elevator. The resident was in his wheelchair with his tray resting on an over-the-bed table. The resident's food was in bowls. He was feeding himself ground ham with a spoon. Further observation of his tray found he also had ham and pineapple chunks in another bowl on his tray. The cover had been removed from the chunks of ham and pineapple. Review of his tray card, located beside his meal, found he was to have ground meat. At 12:44 p.m., Registered Nurse (RN), #28, was observed sitting in a chair beside the resident, feeding him. RN #28 said the kitchen sends both kinds of meals on his tray and, We decide what he can eat. The kitchen doesn't know so they send both. When asked how she decided what consistency of meat to give the resident today, she replied, Well I don't think he can eat the chunks today. Review of the current physician's orders [REDACTED]. Further review of a nutritional assessment, completed by the registered dietician, #84, dated 08/04/16, noted the following: (Name of resident) was having difficulty chewing his meats recently and therefore diet order was modified to mechanical soft with ground meats, which is well tolerated. He can feed himself some, after tray is set-up but needs assistance in completing his meals The food services supervisor (FSS) #53, was interviewed at 11:16 a.m. on 11/03/16. She verified the resident should have received only the ground ham as his tray ticket directed. She said, We don't sent a regular diet and a diet with ground meats. The nurses cannot choose what the resident will eat. At 4:00 p.m. on 11/03/16, the administrator was informed of the above findings. No further information was presented before the close of the survey at 12:00 p.m. on 11/04/16.",2020-02-01
4144,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,309,G,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review the facility failed to provide prompt pain management to Resident #32 when he was experiencing pain in his legs and back. From 12:00 a.m. until 5:30 a.m.on 10/13/16 the facility failed to effectively treat Resident #32's pain when a treatment option was available to them. This failure caused Resident #32 to suffer undo pain for a prolonged period of time resulting in actual harm. In addition the facility on multiple occasions failed to assess the effectiveness of Resident #32's as needed pain medication in a prompt manner. Also for Resident #32 the facility failed to administer his physicians prescribed atvian as directed by the physicians order. This was true for one (1) of four (4) residents reviewed for the care area of pain management during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #32. Facility Census: 29 Findings Include: a) Resident #32 1. Pain Management - Failure to provide prompt pain management. A review of Resident #32's medical record found the following physicians orders: -- [MEDICATION NAME] 5/ [MEDICATION NAME] 325 milligrams (mg) (Brand name [MEDICATION NAME]) every eight (8) hours as needed for pain. This order had a start date of 06/08/16 and was a current order at the time of this review. -- [MEDICATION NAME] 500 mg (Brand Name Tylenol) every four hours as needed for pain. This order had a start date of 07/08/16 and was a current order at the time of this review. Further review of the record found a nursing progress note dated 10/13/16 which read as follows (typed as written), Resident woke up around 12 am (12:00 a.m.) to use the bathroom and c/o (complained of) leg and back pain and Tylenol was given with very little effectiveness (he woke up several more times this shift c/o of leg pain). At appox (approximately) 530am (5:30 a.m.), resident was given [MEDICATION NAME] and OOB (out of bed), toileted and given a snack and a cup of coffee. At, 645 (6:45 a.m.), he was sitting in geri chair in pleasant mood and answered, Oh yes indeedy, they feel better, when asked how his legs and back felt. No further problems noted this shift. This note was written by Licensed Practical Nurse (LPN) #77. A review of Resident #32's Medication Administration Record [REDACTED]. The LPN noted Resident #32 continued to suffer with pain until 5:36 a.m. when she finally administered the resident his as needed [MEDICATION NAME]. During an interviews with the Director of Nursing (DON) at 2:32 p.m. on 11/02/16 and at 10:10 a.m. on 11/03/16, the DON agreed that LPN # 77 should have administered Resident #32's [MEDICATION NAME] prior to 5:36 a.m. She indicated, the effectiveness of an as needed pain medication should be assessed between 30 minutes to an hour after its administration and if the Tylenol was not effective he should have been administered the [MEDICATION NAME]. The DON indicated she did not know why the LPN would have not administered the [MEDICATION NAME] if Resident #32 had continued to complain of pain in his back and legs. An additional interview with the DON at 8:35 a.m. on 11/04/16, found she had spoken with the Health Service Workers (HSW) that were working the night of 10/13/16 and they reported to her that the resident rested well from 12:00 a.m. until 5:36 a.m. when they got him out of bed. She indicated she did not know why LPN #77 would write such a note. She agreed the note did not reflect the information which was obtained from the HSWs. She agreed the note entered into the chart by the LPN responsible for his care indicated the resident went from 12:00 a.m. to 5:36 a.m. without relief from his pain when he had an as needed [MEDICATION NAME] order which could have been administered after the Tylenol was found to be ineffective. b) Prompt assessment of effectiveness after the administration of an as needed pain medication. A review of Resident #32's medical record found the following physicians orders: -- [MEDICATION NAME] 5/ [MEDICATION NAME] 325 milligrams (mg) (Brand name [MEDICATION NAME]) every eight (8) hours as needed for pain. This order had a start date of 06/08/16 and was a current order at the time of this review. -- [MEDICATION NAME] 500 mg (Brand Name Tylenol) every four hours as needed for pain. This order had a start date of 07/08/16 and was a current order at the time of this review. Review of the MAR from 06/08/16 through present found the following occasions when Resident #32 was administered Tylenol and/or [MEDICATION NAME] and prompt assessments of the medications effectiveness was not completed: For the administration of [MEDICATION NAME]: -- 06/16/16 administered at 8:08 a.m. the effectiveness was not assessed until 06/17/16 at 7:54 a.m. (23 hours and 46 minutes after administration). -- 06/17/16 administered at 8:24 a.m. the effectiveness was not assessed until 06/17/16 at 12:57 p.m. (4 hours and 33 minutes after administration). -- 06/20/16 administered at 8:20 p.m. the effectiveness was not assessed until 06/23/16 at 7:34 p.m. (2 days 23 hours and 14 minutes after administration). -- 06/21/16 administered at 4:10 p.m. the effectiveness was not assessed until 06/21/16 at 8:05 p.m. (3 hours and 55 minutes after administration). -- 06/22/16 administered at 8:47 p.m. the effectiveness was not assessed until 06/23/16 at 5:16 a.m. (8 hours and 29 minutes after administration). -- 06/24/16 administered at 5:31 p.m. the effectiveness was not assessed until 06/25/16 at 5:40 a.m. (12 hours and 9 minutes after administration). -- 06/26/16 administered at 12:32 a.m. the effectiveness was not assessed until 06/26/16 at 5:22 a.m. (4 hours and 50 minutes after administration). -- 08/03/16 administered at 2:32 p.m. the effectiveness was not assessed until 08/08/16 at 1:56 p.m. (4 days 23 hours and 24 minutes after administration). -- 08/10/16 administered at 11:31 a.m. the effectiveness was not assessed until 08/10/16 at 2:39 p.m. (3 hours and 08 minutes after administration). -- 08/23/16 administered at 7:04 p.m. the effectiveness was not assessed until 08/26/16 at 3:00 p.m. (2 days 19 hours and 56 minutes after administration). -- 08/24/16 administered at 9:02 p.m. the effectiveness was not assessed until 08/25/16 at 12:06 p.m. (15 hours and 4 minutes after administration). -- 09/14/16 administered at 5:45 a.m. the effectiveness was not assessed until 09/15/16 at 5:16 a.m. (23 hours and 31 minutes after administration). -- 09/25/16 administered at 5:36 a.m. the effectiveness was not assessed until 09/25/16 at 8:32 a.m. (2 hours and 56 minutes after administration). -- 10/11/16 administered at 2:15 a.m. the effectiveness was not assessed until 10/11/16 at 5:19 a.m. (3 hours and 7 minutes after administration). -- 10/13/16 administered at 5:36 a.m. the effectiveness was not assessed until 10/13/16 at 1:27 p.m. (7 hours and 51 minutes after administration). -- 10/20/16 administered at 8:28 a.m. the effectiveness was not assessed until 10/20/16 at 2:45 p.m. (6 hours and 17 minutes after administration). For the administration of Tylenol: -- 07/20/16 administered at 9:12 a.m. the effectiveness was not assessed until 07/20/16 at 1:23 p.m. (4 hours and 11 minutes after administration). -- 07/21/16 administered at 7:41 p.m. the effectiveness was not assessed until 07/26/16 at 5:46 a.m. (4 days 10 hours and 5 minutes after administration). -- 10/15/16 administered at 7:55 p.m. the effectiveness was not assessed until 10/16/16 at 6:27 a.m. (10 hours and 32 minutes after administration). During an interview with Registered Nurse (RN) #24 at 11:04 a.m. on 11/03/16, she indicated one of the supervising nurses run a report at the end of every shift and if there is missing pain documentation then a note is sent to the nurse who administered the medication that she needs to go into the computer and supply the missing documentation. When asked why on some occasions the documentation was entered days later she stated, The nurse who gave the medication may be off for a few days and not be back to supply the needed documentation. She indicated that perhaps they needed to run the report a little more often and have the nurses supply the documentation before they leave for the day. Review of the facility's Assessment and Documentation of Pain policy found the following in regards to monitoring the effectiveness of a medication used to treat pain (typed as written): Monitor effectiveness of medication 30 minutes post administering the medication consider all the relevant factors: 1. Is there a change of behavior which leads you to believe the medication is working? 2. What level of relieve id the resident obtaining at this point in time? 3. Do you have reason to believe the medication is relieving the pain and will do so without other intervention? 4. If complete relief is not obtained return to check in an hour? 5. How long does the effectiveness of the medication last? Is there reason to believe the medication would be more effective at a higher dosage or increased frequency? 6. On some occasions does the medication need to be decreased? 7. Should medication be given q4h prn (every four (4) hours as needed schedule every four hours for 24 hours? To see if changing it to a schedule would make the resident pain free. 8. Is there some reason to believe the medications needs changed? 9. To report to a doctor the medication is not relieving the pain, you must know how much relief was obtained and how long did the relief last. YOU MUST D[NAME]UMENT During an interview with the DON at 2:32 p.m. on 11/02/16 she indicated the nurse should go back 30 minutes to one hour after giving a pain medication to evaluate for its effectiveness she was asked to review the MAR for Resident #32 and she agreed these assessments were not completed timely. During an additional interview with the DON at 8:35 a.m. on 11/04/2016, she confirmed the facility did not follow their policy in monitoring for the relief of pain within 30 minutes to one (1) hour after the administration of a pain medication. She indicated, she felt the nurses did monitor for effectiveness but their documentation is very poor and there is no way to know for sure when they monitored for the effectiveness or if it was effective or not. 2. Failure to administer medications per physician orders. A review of Resident #32's medical record found a physicians order for [MEDICATION NAME] .5 milligrams (MG) twice daily beginning on 06/30/16. This order was in effect until 07/13/16 when it was discontinued. There were no parameters to hold the medication if the resident was sedated. On 07/13/16 the physician changed Resident #32's [MEDICATION NAME] order to .25 mg twice daily and gave the parameter to hold if sedated. A review of the Medication Administration Record [REDACTED] -- 07/03/16 - 8:00 p.m. dose and the reason for holding the medication noted as Lethargy -- 07/04/16 - 8:00 a.m. and 8:00 p.m. doses and the reason for holding the medication on both occasions was Lethargy -- 07/05/16 - 8:00 a.m. dose and the reason for holding the medication Lethargy -- 07/05/16 - 8:00 p.m. dose and reason for holding the medication was listed as Doctors order -- 07/06/15 - 8:00 a.m. dose and the reason for holding the medication was again Lethargy -- 07/06/16 - 8:00 p.m. dose and the reason for holding the medication was listed as Doctors order -- 07/07/16 - 8:00 a.m. and 8:00 p.m. doses and the reason for holding the medication on both occasions was Lethargy -- 07/08/15 - 8:00 a.m. dose and the reason for holding the medication was Lethargy -- 07/09/15 - 8:00 a.m. dose and the reason for holding the medication was Lethargy Further review of Resident #32's medical record found no evidence the physician was notified when this medication was held. The record contained no order to hold Resident #32's [MEDICATION NAME] until 07/13/16 when the doctor was in the facility and saw the resident and decreased his dose of [MEDICATION NAME] and added the parameter to hold the medication if Resident #32 was sedated. An interview with the DON at 4:36 p.m. on 11/03/16 confirmed his medication was held on the above mentioned dates. She indicated she was certain that the physician knew they were holding the medicine, but agreed it was not documented in his record until 07/13/16. She stated, (Name of Attending Physician) was out of town and (Name of another physician) was covering for him in his absence and he came up to the floor frequently and she knows they had to have told him they were holding the medication. She indicated that once he was started on that medication he just went to sleep for days and that is why they were not giving it to him.",2020-02-01
4145,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,312,D,0,1,JLJC11,"Based on resident interview, resident observation, staff interview and record review the facility failed to ensure that Resident #2's oral needs were met on a consistent basis. Resident #2 was unable to care for her dentures which includes placing them in her mouth each morning and staff failed to assist her with this activity of daily living (ADL). This was true for one (1) of three (3) residents reviewed for the care area of ADL's during Stage 2 of the Quality Indicator Survey. Resident identifier: #2. Facility census: 29. Findings include: a) Resident #2 A Stage 1 interview and observation with Resident #2 at 11:36 a.m. on 11/01/16 found the resident to be edentulous. When asked if she had dentures she stated, Yes. When asked why she was not wearing them the resident stated, Because they need cleaned. At 10:28 a.m. on 11/02/16, Licensed Practical Nurse (LPN) #23 was asked if Resident #2 wore dentures. She stated, She has not had dentures the entire time I have been here. (LPN #23's hire date was 04/27/12). When advised what Resident #2 had stated in Stage 1, LPN #23 stated, Let's go talk to her. Resident #2 was interviewed by LPN #23 in the blue room. The resident reported she had dentures. When asked by the surveyor why she did not wear her dentures she stated, They need cleaned. LPN #23 asked her where her dentures were to which Resident #23 replied, In my top drawer. LPN #32 took Resident #2 to her room and opened her top drawer on her night stand and found Resident #2's dentures in a denture cup. Upon observation of the dentures they did not appear to be dirty. The nurse got a toothbrush and some toothpaste and cleaned the resident ' s dentures. LPN #23 then assisted Resident #2 by placing her dentures in her mouth. Resident #2 communicated they were loose and needed some adhesive. LPN #23 left the room and returned with a tube of denture adhesive she put the adhesive on Resident #2's dentures and placed them back into her mouth. Resident #2 indicated that her dentures may need to be adjusted and LPN #23 explained she would have the dentist come to the facility to see her and to align her dentures. LPN #23 agreed Resident #2 was not able to care for her own dentures and staff would need to assist her with cleaning them and placing them in her mouth for her. A review of Resident #2's Kardex (an information sheet used by the facility to communicate the care needs of residents to the health service workers) found the following under the heading oral care, no dentures or teeth have resident rinse after meals. Also under the heading Eating/Drinking/Diet the following was noted, resident has no teeth or dentures. A review of Resident #2's Nursing Aide flow sheets for the previous three (3) months found at no time was denture care provided to Resident #2. At 11:24 a.m. on 11/02/16, Resident #2 was observed in the hallway by the nurses station. She was still wearing her dentures. The Director of Nursing (DON) talked to her at this time. When the DON asked her why she had not been wearing her dentures Resident #2 stated, They needed cleaned. The DON stated in an interview at this time she knew Resident #2 had dentures but thought she had refused to wear them. She indicated she would instruct staff to clean the resident ' s dentures in front of her so that she would know they were clean when placed in her denture cup. The Kardex was reviewed with the DON and she stated, I don't know why they have on there that she does not have dentures. The DON went on to further state she thought Resident #2 was just wearing her dentures to please the surveyor and once we left she would stop wearing them again. Observation of Resident #2 completed at 11:59 a.m. on 11/02/2016 ,found her showing her dentures to another resident. The other resident stated, You got your teeth in good. To which Resident #2 just smiled. Resident #2 was observed eating her noontime meal on 11/02/16 at 12:24 p.m., she indicated she was able to eat her meal with no problems and her teeth felt fine. An observation of Resident #2 on 11/03/16 at 11:52 a.m. found the resident sitting in the solarium. Her dentures were still in place. The resident offered no complaints of pain associated with wearing her dentures. A final observation of Resident #2 on 11/04/16 at 9:30 a.m. found she was sitting in the solarium. She stated she was getting ready for a shopping trip. Her dentures were in place and she offered no complaints of pain.",2020-02-01
4146,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,329,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for the care area of unnecessary medication use was free from unnecessary drugs. The resident's physician failed to address indications for continued use of an antianxiety and an antidepressant medication after the pharmacist recommended a gradual dose reduction (GDR). Resident identifier: #28. Facility census: 29. Findings include: a) Resident #28 The pharmacist completed a drug regimen review on 07/20/16. The pharmacist noted the resident was receiving the following medications: [REDACTED] --[MEDICATION NAME] 5 milligrams (mg) daily, since 01/05/16. --[MEDICATION NAME] 0.25 mg twice a day, since 01/21/16. A recommendation was made to, Please evaluate for the lowest possible effective dose and consider a dosage reduction at this time. The physician had signed the pharmacist's review and written, No change. The date the physician reviewed the report was not recorded. The resident was admitted with [MEDICATION NAME] 5 mg daily for a [DIAGNOSES REDACTED]. At 4:15 p.m. on 9:52 a.m. on 11/02/16, the Director of Nursing (DON) was interviewed regarding the pharmacist recommendation. The DON stated the [MEDICATION NAME] was added because the resident kept trying to leave the facility and the resident's daughter told the DON the resident had taken [MEDICATION NAME] in the past. The DON confirmed she was unable to find documentation from the physician as to why a GDR would be clinically contraindicated for Resident #28.",2020-02-01
4147,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,365,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure Resident #14 received the diet prescribed by the attending physician. This was a random opportunity for discovery during a meal observation. Resident identifier: #14. Facility census: 29. Findings include: a) Resident #14 Observation of the first meal upon entrance to the facility, the noon meal at 12:39 p.m. on 10/31/16, found the resident was seated in the lounge area near the elevator. The resident was in his wheelchair with his tray resting on an over-the-bed table. The resident's food was in bowls. He was feeding himself ground ham with a spoon. Further observation of his tray found he also had ham and pineapple chunks in another bowl on his tray. The cover had been removed from the chunks of ham and pineapple. Observation of his tray card, located beside his meal, found he was to have ground meat. At 12:44 p.m., Registered Nurse (RN) #28, was observed sitting in a chair beside the resident, feeding him. RN #28 said the kitchen sends both kinds of meal on his tray and, We decide what he can eat. The kitchen doesn't know so they send both. When asked how she decided what consistency of meat to give the resident today, she replied, Well I don't think he can eat the chunks today. Review of the current physician's orders [REDACTED]. Further review of a nutritional assessment, completed by the registered dietician, #84, dated 08/04/16, noted the following: (Name of resident) was having difficulty chewing his meats recently and therefore diet order was modified to mechanical soft with ground meats, which is well tolerated. He can feed himself some, after tray is set-up but needs assistance in completing his meals The food services supervisor (FSS) #53, was interviewed at 11:16 a.m. on 11/03/16. She verified the resident should have received only the ground ham as his tray ticket directed. She said, We don't sent a regular diet and a diet with ground meats. The nurses cannot choose what the resident will eat.",2020-02-01
4148,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,371,E,0,1,JLJC11,"Based on observation and staff interview the facility failed to ensure expired nutritional supplements were not available for use in the kitchen. This practice had the potential to effect more than an isolated number of residents. Facility Census: 29. Findings include: a) Tour of the Kitchen An initial tour of the kitchen at 11:35 a.m. on 10/31/16, found six (6) eight (8) ounce cans of Glucerna which had a manufacture stamped expiration date of 10/01/15. This Glucerna had been expired for 13 months and was located in the white combo refrigerator in the facility's kitchen. Also in the dry storage area was 27 eight (8) ounce cans of Ensure original butter pecan flavor which had a manufacture stamped expiration date of 10/01/16. The food service supervisor (FSS) #53 was present during the entire tour and confirmed the Glucerna and Ensure were expired, but were still available for use and needed to be discarded.",2020-02-01
4149,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,463,D,0,1,JLJC11,"Based on observation and staff interview the facility failed to ensure Resident #32's call light was functioning at all times. This was true for one (1) of 26 Stage 1 sampled residents. Resident identifier: #32. Facility Census: 29. Findings include: a) Resident #32 At 9:33 a.m. on 11/01/16, Resident #32's call light button was depressed. Upon depression of the button the call light outside of the resident ' s door did not light up nor did the light at the nurse ' s station. Licensed Practical Nurse (LPN) #23 was summoned to the room. She was asked to pushethe call bell button assigned to Resident #32's bed. She pushed the button and again the light outside the door nor the light at the nurse ' s station illuminated. She paged for maintenance to come to the room. He entered the room and got the light to work. LPN #23 stated that it must have been loose and not making a good connection, but he got it fixed. At 3:52 p.m. on 11/01/16 Resident #32's call light button was again depressed. Again upon depression of the button the call light outside of the resident door nor the light at the nurse ' s station illuminated. The Director of Nursing (DON) was asked to come into the room. The call button was depressed several more times without the light outside the door or the light at the nurse ' s station illuminating. The call light finally did illuminate the light outside the room and at the nurse ' s station after depressing the button several more times. The DON indicated that there must be something wrong inside the cord and it would need to be replaced. She stated for tonight, we will switch it with bed one (1) since the resident does not have roommate, and then have maintenance fix it in the morning.",2020-02-01
4150,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,502,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to obtain physician ordered laboratory services for one (1) of four (4) residents reviewed for pain management. The facility failed to obtain a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), [MEDICATION NAME] level and a Vitamin D 25 [MEDICATION NAME] level for Resident #8. Resident identifier: #8. Facility census: 29. Findings include: a) Resident #8 A review of Resident #8's medical record at 9:45 a.m. on 11/02/16 found a physician's orders [REDACTED]. Further review of the medical record found Resident #8 should have had the CBC, BMP, [MEDICATION NAME] and Vitamin D 25 [MEDICATION NAME] levels obtained on 08/29/16, but the facility failed to obtain this lab as ordered. The laboratory tests were not obtained until 09/12/16. At 12:32 p.m. on 11/02/16, the Director of Nursing (DON) was asked to provide the results of the CBC, BMP, [MEDICATION NAME] and Vitamin D 25 [MEDICATION NAME] levels that was ordered for 08/29/16. She provided a copy of the lab results obtained on 09/12/16. She was unable to find the reason why the lab was not obtained on the 08/29/16.",2020-02-01
4151,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,520,C,0,1,JLJC11,"Based on record review and staff interview, the facility's quality assessment and assurance (QA & A) program failed to meet quarterly as required. This practice has the potential to effect all residents currently residing in the facility. Facility census: 29 Findings include: a) Meets at Least Quarterly Review of the facility's QA & A committee sign-in sheets for the previous year found the committee met on 02/10/16, 04/20/16 and 07/27/16, which did not represent a meeting every quarter. After this review, the Director of Nursing (DON) stated she was on vacation when one of the meetings was to be held in (MONTH) for the 3rd quarter of (YEAR), and that meeting was not held.",2020-02-01