cms_WV: 10723
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 |
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10723 | GLEN WOOD PARK, INC. | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-08-24 | 157 | D | 1 | 0 | HTIL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and record review the facility failed to immediately notify the physician of one (1) of six (6) sampled resident's death. Resident #60 was a full code. She was found by nursing staff with no pulse and no respirations on [DATE]. Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Resident #60 had elected to be a full code. Review of the nurses' notes for [DATE] revealed the following entries (quoted as written): - On [DATE] at 4:40 a.m.: "nursing assistants entered resident's room and found resident unresponsive and came to get nurses. Upon examining resident - 0 pulse or heartbeat noted no breathe sounds notes. Tongue hanging out of mouth - head turned to L side Body cold and stiff. Resident obviously expired." - On [DATE] at 4:41 a.m.: "Family was notified of death." - On [DATE] at 4:42 a.m.: "Funeral Home was notified of death." - On [DATE] at 4:44 a.m.: "Senior vice president was notified of death." - On [DATE] at 4:45 a.m.: "Vice president of resident services was notified of death." - On [DATE] at 5:00 a.m.: "RN on call was notified of death." Review of the nursing notes found no evidence that the physician was notified. - On [DATE], interviews were conducted with the following employees: - Employee #52 (certified nursing assistant), when interviewed at 1:30 p.m., stated he had entered the room at 4:40 a.m. to reposition the roommate of Resident #60. At this time, he noticed Resident #60 was turned sideways and "... her tongue was drooped and purplish colored." He stated he told Employee #73 (certified nursing assistant), "She looks like she passed away." He left the room to tell the nurse (Employee #64). - Employee #73, when interviewed at 2:30 p.m., verified she and Employee #52 found Resident #60 around 4:00 a.m. She stated, "She felt cold and her tongue was hanging out of her mouth." - Employee #64 (licensed practical nurse) was interviewed at 10:30 a.m. When asked if she knew the code status prior to Resident #60's death, Employee #64 replied, "No, I thought she was comfort measures." Employee #64 further stated, "I didn't call the doctor." - On [DATE] at 9:24 a.m., the director of nursing (Employee #80) stated, "We do not have to call the physician, we tell him on his next round." She further stated, "They do not have to call him if they are a full code." . | 2014-12-01 |