cms_WV: 10312
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10312 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 272 | D | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and resident interview, the facility failed, for three (3) of twenty-one (21) Stage II sample residents, to complete initial and/or periodic comprehensive assessments of each resident's functional capacity, to include assessments of skin condition, bladder continence, and nutritional status. Resident identifiers: #9, #31, and #53. Facility census: 34. Findings include: a) Resident #9 When interviewed on 05/03/10 at 3:45 p.m. about the status of Resident #9's skin integrity, Employee #18 (a licensed practical nurse - LPN) stated the resident had an open area on each heel and he "came from hospital with them." When reviewed on 05/12/10, the resident's medical record disclosed this [AGE] year old had been admitted to the facility from a local hospital on [DATE], following repair of a [MEDICAL CONDITION] that he had incurred at home. The resident's nursing admission assessment made no mention of skin breakdown other than describing the area of the surgical wound on the resident's left hip. Nursing notes and physician orders [REDACTED]. A nurse's note, dated 02/03/10 at 12:20 p.m., stated, "Resident complained of heels hurting this am (morning). Heel up (sic) off bed. Both heels black area. Told charge nurse." Orders were received, and treatment was started to the heels at that time. An additional nurse's note, dated 03/01/10, stated a physician questioned the resident and his wife related to the areas on his heels, and both the resident and his wife agreed that his heels had been sore since he was at home, prior to his hospitalization for the [MEDICAL CONDITION]. When interviewed on 05/12/10 at 4:07 p.m., the facility's care plan and assessment nurse (Employee #25) confirmed the skin integrity of the resident's heels, according to the resident and family, had been somehow compromised at the time of admission to the ECU. This employee stated the ECU protocol for skin assessments was for an assessment to be completed on the resident at the time of admission and then monthly thereafter by the nurse, unless there was a recognized skin issue; then, a weekly skin assessment (wound assessment) was completed. This nurse further confirmed that no assessment of the resident's heels had been completed until the resident complained of pain on 02/03/10. The resident's MDS documents, when reviewed, disclosed that both the admission MDS (with an assessment reference date (ARD) of 01/17/10) and the Medicare 14-Day MDS (with an ARD of 01/24/10) made no mention, in Section M, of the resident having any skin breakdown. The resident's next MDS (with an ARD of 02/09/10) described the resident, in Section M, as having four (4) Stage IV pressure ulcers. -- b) Resident # 31 Medical record review, on 05/12/10, revealed this resident was incontinent of bladder when admitted on [DATE]. A six-page bladder incontinence assessment form was found in the medical record; however, it had not been completed. This form also contained the protocols for assessing residents with urinary incontinence. At 2:00 p.m. on 05/12/10, the director of nursing (DON - Employee #31) and the vice president of patient care services (Employee #32) were asked if they would locate a completed bladder incontinence assessment for this resident. Each reviewed the medical record and checked other sources, then confirmed no such assessment had been completed. At 11:00 a.m. on 05/13/10, the resident was interviewed regarding her incontinence. At that time, the resident stated she could feel the urge to urinate and would like to be continent of urine if at all possible. -- c) Resident #53 Review of this resident's medical record, on 05/12/10, revealed a weight of 101.4 pounds (#) on 03/02/10, and a weight of 94.6# on 04/02/10. There was no evidence the resident was reweighed to confirm or dispute this six and seven-tenths percent (6.7%) weight loss in one (1) month. If the weight loss were accurate as recorded, the facility should have immediately acted on this significant weight loss. There was no evidence the weight loss had been further assessed or addressed. Interview with Employee #32, at 2:05 p.m. on 05/12/10, revealed nursing staff should have reweighed the resident when there was such a variance in weight. When asked how staff would know this should be done, Employee #32 stated, "They just know to do so, but they did not." When a request was made for a policy and procedure regarding weights, Employee #32 stated no such policy existed. . | 2015-05-01 |