cms_WV: 10218
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10218 | PRINCETON HEALTH CARE CENTER | 515187 | 315 COURTHOUSE RD. | PRINCETON | WV | 24740 | 2010-04-15 | 281 | D | 0 | 1 | WIXO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the medical record, observation, and staff interview, the facility failed to assure that services provided to the residents met professional standards of quality for two (2) of fifty (50) sampled residents. For Resident #128, weights were not recorded in a manner to allow the accurate assessment of the resident's nutritional status, and there was no evidence to reflect staff followed the facility's policy and procedure to assure weight loss was promptly addressed. For Resident #18, observation found eye drops were not administered as ordered by the physician. Facility census: 118. Findings include: a) Resident #128 Review of Resident #128's medical record revealed the weight record consisted of a form that provided, for each month, multiple spaces to record weights and the dates on which they were obtained. At the top of Resident #128's weight record, staff recorded his admission weight as 116.4 pounds (#) on 03/01/10. Also recorded in the month of March 2010 was a weight of 116.4# with no date noted as to when this weight was obtained. Upon reviewing the form, the medical records staff member (Employee #42) confirmed the resident's admission weight was written in the March 2010 column and verified this was only one (1) weight recorded on that form as of 04/13/10. The registered nurse (RN) case manager (Employee #142), when questioned as to why no further weights were recorded on this form for Resident #128 since his date of admission, informed this surveyor the resident's weights were recorded in the computer and she would have to print them off. At 10:00 a.m. on 04/13/10, Employee #142 provided a print out of all weights recorded in the computer for Resident #128. Review of the weights from the computer found the resident's admission "base weight" was recorded as 125#. When the resident was weighed on 03/23/10, his weight was 117#. According to this documentation, the resident lost 8.6# from 03/01/10 to 03/23/10. According to the medical record, the resident experienced an episode of decreased level of consciousness, his oxygen saturation decreased, and he developed a fever. He was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].) over a month period. Dietary Consult, notify POA." This order was written while the resident was in the hospital, and there was no evidence to reflect these actions had been taken prior to that time, even though the weight loss was identified on 03/23/10. The resident was re-admitted on [DATE]. His weight on readmission was 112#. Upon his return to the facility, there was no evidence to reflect the notification of weight loss was given to the resident's family or a consult with the registered dietitian was arranged pursuant to the 04/05/10 order. A review of the facility's policy stated that, for residents showing a weight loss of 5# or more in one (1) month, staff was to notify the resident's responsible party and obtain an order a dietary consult. According to the policy, "Section L on the MDS will be addressed by the care plan committee." There was no evidence to reflect this policy had been followed when the resident's weight loss was identified on 03/23/10. During an interview with Employee #142 on 04/15/2010 at 9:15 a.m., she reported this recorded weight must have been entered wrong. She stated she did not think there had been a weight loss. She was no sure where the base weight of 125# had come from. She also verified the weight of 114# recorded in the resident's comprehensive admission assessment, with an assessment reference date of 03/08/10, was incorrect. (See also citation at F278.) Employee #142 stated she did not realize these weights were incorrect until the survey. The facility's policy was not followed regarding the interventions to be initiated in the event of a weight loss. b) Resident #18 During medication administration pass on 04/14/10 at 6:05 p.m., observation found Employee #36 prepared the resident's oral medications and placed her bottle of eye drops on a tissue on the Medication Administration Record [REDACTED]. She put the eye drops back into the drawer without having administered any. When asked about the eye drops, she agreed she had not given them. . | 2015-06-01 |