cms_WV: 10269
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
10269 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-09-26 | 514 | C | 0 | 1 | FJI611 | . Based on observation and staff interview, the facility failed to maintain complete clinical information which was readily accessible for resident care. Review of the facility's medical records found less than two (2) months of clinical information in residents' charts. This practice affected all residents on the QIS survey sample. Additionally, the facility continued to document nursing information on a resident who was discharged from the facility. Resident identifier:#12. Facility census: 109. Findings include: a) Thinning of Medical Records Observation of the medical records for residents during the entire survey beginning on 09/16/12, discovered only one (1) month and seventeen (17) days of nursing information was accessible on the residents' medical records. According to the facility's "Active Medical Record Index With Thinning Guidelines," the facility was supposed to leave three (3) months of current nursing information on the chart. On 09/26/12, at approximately 1:15 p.m., Employee #83 (medical records director) stated, "Sometimes the charts get too full and I have to thin them." b) Resident #12 Review of the medical record found this resident was discharged to home on 08/03/12. Further review of the nurses' notes found nursing staff continued to document in this resident's medical record, after the resident no longer resided in the facility, as though the resident was in the building on 08/05/12 and 08/06/12. Both nursing notes referenced, " ...call light within reach. " The administrator and the director of nursing were made aware of the above situation on 09/20/12 at 10:30 a.m. No further information was provided by the facility. | 2015-05-01 |