cms_WV: 10318
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10318 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 323 | G | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed, for one (1) of twenty-one (21) Stage II sample residents, to provide a resident environment as free of accident hazards as possible, by failing to ensure staff consistently secured and alarmed an exit door leading from the unit to a stairwell. This practice resulted in actual harm for Resident #30 when she exited the door unnoticed and fell down eight (8) steps in her wheelchair, sustaining an acromioclavicular joint separation (separated shoulder). Resident identifier: #30. Facility census: 34. Findings include: a) Resident #30 Review of the facility's incident / accident reports, on 05/11/10, revealed a report stating that, on 03/23/10 at 11:00 a.m., Resident #30 was found in a stairwell off the Extended Care Unit (ECU) at the bottom of eight (8) stairs. Further review of the document disclosed that, following investigation, it was determined a staff member had failed to utilize the proper method of securing the door and re-setting the door alarm after another resident had activated the alarm the day before. This information was confirmed in an interview with vice president of patient care services (Employee #32) on the morning of 05/13/10. The resident's medical record, when reviewed on 05/12/10, disclosed this [AGE] year old female was known to the facility to wander and to be at risk for falling. According to the resident's care plan, which was reviewed on 05/12/10, staff was aware the resident was a high risk for falls related to a history of falls. Interventions to assure the resident was free from falls included measures such as providing activities that minimize the potential for falls while providing diversion and distraction and applying a bed alarm and an EZ release seat belt while in wheelchair. The resident also wore a WanderGuard alarming device / bracelet, but this door was not equipped with the WanderGuard system. Review of the resident's minimum data set (MDS) assessments disclosed an MDS with an assessment reference date of 02/24/10. In Section E (Mood and Behavior), the assessor noted the resident exhibited wandering one (1) to three (3) days in the seven-day assessment reference period. The resident was noted in Section B (Cognitive Skills) to be moderately impaired in cognitive skills for daily decision-making, and in Section G (Physical Functioning), the resident was noted to range from needing extensive assistance to being totally dependent for completing most activities of daily living. When the resident was discovered following the fall, nurses' notes stated she was "lying on face / left side with wheelchair on back. Had to release EZ release seat belt to get w/c (wheelchair) off resident." The resident was secured to a back board and transferred to the emergency room (ER). The resident underwent [REDACTED]. There was acromioclavicular joint separation (separated shoulder), the resident returned to the ECU with a sling on the left arm, and the resident's pain medication was increased. . | 2015-05-01 |