cms_WV: 10728
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10728 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 412 | D | 0 | 1 | H9I611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to identify the need, and arrange dental services, for one (1) of twenty-three (23) Stage II sample residents, to assure she was not experiencing complications (such as pain or infection) related to the poor condition of her oral cavity. This resident was observed to have multiple broken, carious teeth which had not been identified as a concern by the facility, and for which no referral had been made to a dentist for possible intervention. Resident identifier: #33. Facility census: 49. Findings include: a) Resident #33 While in the dining area at 2:00 p.m. on 10/11/10, observation found Resident #33 with her head tilted back and her mouth opened, which allowed this surveyor to see she had several teeth missing. She had one (1) black tooth in poor condition in the right upper side of her mouth; there were no other teeth present in that area. She also had two (2) broken teeth in the front on the bottom that were just barely above the gum line. Review of Resident #33's medical record found no evidence that a complete oral examination had been performed on this resident. She was admitted to the facility 06/12/06. On 10/13/10 at 4:00 p.m., a licensed practical nurse (LPN - Employee #88) was asked to perform an oral exam on this resident, so the inside of her mouth could be further observed. Employee #88 attempted to use a tongue depressor to view the inside of Resident #33's mouth; the resident did not want to open her mouth and resisted attempts to view inside her mouth. The resident finally allowed the nurse to look briefly inside her mouth, and the nurse confirmed the resident's teeth were in poor condition. The nursing assistant providing care for the resident on 10/13/10 (Employee #50), when interviewed at 5:00 p.m., was questioned about providing oral care for this resident. Employee #50 stated this resident often would not allow her to provide oral care and would clench her mouth tightly so that she could not get inside her mouth. She said, "You have to just return later and try again because, later, she might let you do it." She also reported the resident had a growth in the roof of her mouth. This resident had [MEDICAL CONDITION] and was not able to communicate her wants and needs to others. She received a pureed diet and often clenched her jaws together when the staff attempted to perform oral hygiene. She was not able to verbalize her needs. Review of the resident's current care plan (which was last reviewed / revised on 09/08/10) found it did not address the oral care. The only approach for her oral status stated, "Monitor for dental / oral problems or problems with her eyes or ears and notify the physician as indicated, podiatry consult as needed." This intervention was not appropriate, because there was no accurate baseline assessment of resident's oral status. She had multiple broken, carious teeth had not been identified on assessment, and there was no evidence that the growth in the roof of her mouth had been assessed. The minimum data set assessment (MDS) nurse (Employee #44) verified, during an interview at 4:30 p.m. on 10/13/10, that no care plan had been developed to accurately describe the care and services needed to address this resident's oral hygiene and/or dental needs. After this issue was identified by the surveyor on 10/13/10, Employee #44 examined the resident's mouth and confirmed the resident had broken teeth and a dark-color upper right tooth. Employee #44 called the resident's daughter, who gave her the name of the dentist the resident had seen in the past. Employee #44 stated the facility would call this dentist to see if he could evaluate the resident here at the facility. There was no evidence in the medical record that the facility had talked to the family about this issue prior to the surveyor's intervention. . | 2014-12-01 |