cms_WV: 10719

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
10719 HUNTINGTON HEALTH AND REHABILITATION CENTER 515007 1720 17TH STREET HUNTINGTON WV 25701 2011-08-22 514 D 1 0 08RC11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the clinical record contained complete and accurate information about a resident's skin condition for one (1) of six (6) sampled residents (#184). On admission, Resident #184 had a Stage 3 pressure ulcer, which later declined to a Stage 4, and for which she received daily treatments. "Nursing Daily Skilled Summary" forms, used by the facility to record assessment information about various body systems, contained check boxes to prompt nurses to record specific information - such as the presence of pressure ulcers. Ten (10) such summary forms, entered in the resident's record between 06/07/11 and 06/24/11, were either left blank or were specifically - and incorrectly - marked "No problems". Additionally, although assessments of her wound were being recorded on a pressure ulcer log used to track the wounds of multiple residents simultaneously, Resident #184's own medical record did not contain a weekly description of the characteristics of her wound as it was being assessed between the dates of 07/05/11 and her date of discharge on 07/13/11. Resident identifier: #184. Facility census: #180. Findings include: a) Resident #184 1. Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE], was readmitted to the facility following a hospital stay on 05/23/11. Assessment information revealed the presence of a Stage 3 pressure ulcer on the resident's coccyx upon her return from the hospital. Review of her physician's telephone orders found an order, dated 05/25/11 at 12:30 p.m., stating (quoted as written): "(1) Cleanse wound to Coccyx /c (with) [MEDICATION NAME], pat dry, apply Santyl. Cover /c 4x4 [MEDICATION NAME]. (Symbols for "change every day') and PRN (as needed) until resolved. @ (At) drsg (dressing) (symbol for 'change') complete daily pressure ulcer monitoring record. (2) Ensure drsg is C/D/I (clean / dry / intact) Q (every) shift to Coccyx." Further review of Resident #184's medical record found a form titled "Nursing Daily Skilled Summary", which was being completed daily by a licensed nurse while she received skilled care. Instructions provided on this form directed the nurse to record all abnormal findings in a narrative format in the space provided. Between the dates of 06/07/11 and 06/25/11, there were ten (10) days on which the section intended record an assessment of the resident's skin condition was either not completed or had checkmarks placed in boxes to indicate the presence of "no problems" and/or "scars" as follows: - 06/07/11 at 11:00 p.m. - "No problems" and "Other - scars" - 06/08/11 (no time noted) - "No problems" and "Other - scars" - 06/10/11 at 8:00 p.m. - "No problems" and "Other - scars" - 06/14/11 at 7:00 p.m. - "No problems" and "Other - scars" - 06/15/11 at 8:30 p.m. - "No problems" - 06/17/11 at 11:00 p.m. - "No problems" - 06/18/11 at 2300 (11:00 p.m.) - Skin assessment section was blank. - 06/19/11 at 2300 (11:00 p.m.) - Skin assessment section was blank. - 06/21/11 at 7:00 p.m. - "Other - ______" (there was no additional information recorded) - 06/24/11 at 1900 (7:00 p.m.) - Skin assessment section was blank. In the section in which the licensed nurse was to record an additional services being provided, the item labeled "Wound care and management" was not checked on any of the above-referenced summaries. Additionally, none of these summaries contained anything in the narrative notes section at the bottom of each form or on the reverse side of each form. -- 2. Further record review found weekly skin records, on which the treatment nurse recorded a description of the wound, including measurements. This was noted to be done weekly until 07/05/11, after which there was no weekly entry. The resident was discharged to home on 07/13/11, and the next weekly skin record should have been recorded on 07/12/11. There was no indication in the medical record that this wound had been assessed since 07/05/11 and prior to her discharge on 07/13/11. This was brought to the attention of the director of nursing (DON) at 2:00 p.m. on 08/22/11. He provided the facility's wound log on which information about all residents' wounds was recorded. The previous week's measurements for each resident's wounds were also recorded on this log, so progress in wound healing could be evaluated. An entry on this log verified that Resident #184's wound was assessed and measured on 07/12/11. The DON stated Resident #184 went home on 07/13/11, and the treatment nurse had not recorded these measurements in the resident's record. There was no documentation in the resident's medical record of the condition of this wound at the time she was discharged . 2014-12-01