cms_WV: 10777
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10777 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2011-08-04 | 204 | D | 1 | 0 | S9PC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, staff interview, and interview with staff at the local hospital, the facility failed to provide sufficient preparation and notice to a resident and her family to ensure an orderly discharge from the facility in a manner that minimizes unnecessary and avoidable anxiety. This was found for one (1) of eight (8) residents' whose records were reviewed. Resident identifier: #43. Facility census: 41. Findings include: a) Resident #43 Closed record review revealed Resident #43 was an [AGE] year old woman who was admitted to the facility on [DATE]. She was transferred to the Behavioral Health Unit at a local hospital for evaluation on 06/26/11, and subsequently discharged permanently from the nursing home on 07/11/11. - The facility's social worker (Employee #34), when interviewed about the 07/11/11 discharge of Resident #43 on 08/02/11 at 2:00 p.m., stated the facility discharged the resident due to concerns about elopements and aggressive behavior. She stated the resident was sent to the Behavioral Health Unit following an elopement on 06/26/11 that had found her some distance away from the facility. A member of the community returned the resident to the facility. The social worker stated the resident had not returned to this nursing home, and the Behavioral Health Unit had discharged her to another nursing facility in Grafton. - Nurses' notes, when reviewed on 08/04/11 at 8:41 a.m., found an entry by a licensed practical nurse (LPN - Employee #68) dated 06/26/11, stating (quoted as written): "3:10pm, received call from a (name of person from community), that she found resident on Market Street by Wes Banco bank. (Name of person from community) brought resident back to facility. Resident very unsteady on her feet and sat down in the nearest chair. Resident continues to say 'They are all jealous of me because I have the spaghetti sauce from Muriales and they don't' Also 'I am getting out of here no matter what you have to say'. Attempted to redirect resident, which is not working. 3:20pm, contacted (name of director of nursing) RN, DON, also contacted (name of social worker) SS, who will be contacting (name of administrator) CEO. 3:25pm, Contacted (name of resident's responsible party) MPOA (medical power of attorney)who is in agreement to transport resident to FGH Behavior unit. 3:50pm, left message for Dr. (name). 3:50pm Contacted MCRS to transport resident to FGH for evaluation. Son, (name) MPOA in to see resident. (Name) Called and was told of behavior and going to FGH ... 4:15pm, MCRS here to transport resident to FGH for evaluation. Also contacted FGH ER and spoke with Nurse (name) who was informed of residents behavior and arrival by squad. 5:18pm, Dr. (name) returned call re: residents behavior and transport to FGH for evaluation." - Review of documentation concerning Resident #43's discharge, conducted on 08/04/11 at 1:00 p.m., disclosed a notice of resident transfer and bedhold policy dated 06/26/11. The form was filled out by hand and stated "(Name of Resident #43) will be transferred to FGH (local hospital) due to: behavior." There followed a statement of facility bedhold policy, which included the statement: "It is the policy of John Manchin Sr. Healthcare to hold the resident's bed for 30 days ... The bedhold will continue unless permanent determination is made regarding the resident's need for care the facility is unable to provide." There followed a section Titled "State Bed Hold Policy", a statement that "The resident has the right to appeal this action to the agencies listed below", and a listing of contact information for the West Virginia Inspector General, the West Virginia Commission on Aging, West Virginia Advocates, and the Regional Ombudsman. The form concluded with the following: "I certify that this notification was given to the party named above: (name of Resident #43), and was dated by hand 6/26/11. Signature of staff member was completed by hand as (Employee #68, LPN)." The final section of the transfer notice stated: "Verification of receipt of notification: This acknowledges that I received the notice of resident transfer and bedhold policy." The "signature of resident / legal representative" field was blank. - In an interview with Employee #68 on 08/03/11 at 2:45 p.m., when asked if she had given a copy of the form to the resident or to the MPOA, replied that that form was not given to either of those individuals, that it was a form that was sent with the emergency squad when a resident is sent out. - During an earlier interview with the nurse manager of the Behavioral Health Unit on 08/03/11 at 11:00 a.m., she had pointed out that the facility sends a form when residents are transferred for evaluation that states they will hold the resident's bed for thirty (30) days. d) A visit was made to the Behavioral Health Unit at Fairmont General hospital on [DATE] at 11:00 a.m. The director and the nurse manager of this unit were interviewed regarding the issues surrounding Resident #43's admission for evaluation and her subsequent discharge to a nursing facility in Grafton. Supporting documentation was requested and provided. The nurse manager stated they had expected Resident #43 to return to the facility, as she had following a brief admission for evaluation in March 2011. Documentation was reviewed as follows: A psychosocial assessment, completed 07/05/11, included under the section "CURRENT LIVING SITUATION / SOCIAL AND COMMUNITY SUPPORT": "... She should be able to return to John Manchin Senior Center pending a completed PAS (pre-admission screen). That will be continuously evaluated by the treatment team; however in a conversation on June 28, 2011, with (Name of son), he stated that it was his goal for their mother to return to that facility." Under the section "SUMMARY AND RECOMMENDATIONS" was found: "... She should be able to return to John Manchin Senior center following discharge." Under the section "INITIAL TREATMENT GOALS / INTERVENTIONS" was found: "... Goals: 1. Prevention of deterioration. 2. Decrease any agitation, aggressiveness and wandering behaviors. 3. Help reorient the patient and maybe decrease some of the agitation through ongoing reorientation to time, place, and situation. Interventions: 1. Medication stabilization. 2. One-on-one interaction to develop some effective coping skills and help facilitate group and individual sessions." Under the section "INITIAL DISCHARGE PLANNING" was found: "... Return to John Manchin Senior Healthcare Center where she currently resides." Phone contact notes stated: On 06/29/11 - "Spoke with (name) at John Manchin Nursing home this day. Discussed DC (discharge) for Friday. (Name) states that PT's (patients) will need to be transported to that facility before 12 so that prescriptions can be filled." On 06/30/11 - "Spoke with (nursing home's social worker) this day regarding DC (discharge) for (Resident #43). Discussed (Resident #43's) recent aggressiveness and behaviors. Discussed a possible DC for Tuesday 7/5/11 pending continued observation. The initial projected DC date was to be 7/1/11, however it is the opinion of TX (treatment) teams at both facilities that PT needs more observation and time for med adjustments to occur." On 07/07/11: "Attempted to contact (name of social worker) at Manchin Healthcare to discuss DC for 7/8/11 as per discussion with Dr. (name) this day. (Name of social worker) was unavailable, message was left on her personal answering machine." On 07/11/11: "Spoke with (nursing home's social worker) at John Manchin Healthcare this day to discuss PT discharge. (social worker) states that John Manchin will not be able to accept PT back, states that this decision is based PT safety concerns and OHFLAC regulations. (social worker) states that she did not agree to accept patient back in her conversation with Dr. (name) which occurred on Friday 7/8/11." A treatment progress note dated 07/11/11 stated: "Met with PT's son's (names), and PT's daughters (names) this day following a discussion with (nursing home's social worker) at John Manchin Sr. Healthcare. On this day PT was to be DC as per a conversation that occurred on 7/8/11 between (social worker) and Dr. (name). When the RN on duty called John Manchin to give DC report (hospital) was informed that John Manchin would not accept the PT back. Discussed with PT's family several options for placement, including (name of another nursing home) which had been contacted with referral information. PT's family prompted this author to make several other referrals, which were faxed this day. PT's family is visiting several nursing homes this day, will contact tomorrow." It was apparent that both Resident #43's family and staff at the Behavioral Health Unit were expecting the resident's return to John Manchin right up until the refusal expressed over the telephone on 07/11/11. The resident was subsequently discharged to another area facility. - An interview was conducted with a son of Resident #43 by telephone at 11:30 a.m. on 08/03/11. He stated the family did not have enough time to transfer their mother to another facility. He further stated he felt administration at this facility did not seem to understand how to care for Alzheimer's patients. He also stated the floor nurses at the facility did the best they could, but administration just did something drastic. - In an interview with the facility's health information management director (Employee #45) on 08/03/11 at 1:25 p.m., when asked to clarify the facility's bedhold policy, she stated the facility holds the bed of a transferred resident for thirty (30) days regardless of payor source or availability of bedhold days through the Medicaid program. She stated that, if a resident's Medicaid allotment of twelve (12) paid bedhold days had already been used, the facility would still hold the bed free of charge for thirty (30) days. - The only documented meeting between the facility's interdisciplinary team and Resident #43's MPOA was a care plan review meeting held on 04/06/11. A social services note stated: "Annual Assessment was done today for (Name of Resident #43). Her son and MPOA, (name), attended the meeting. The IDT (interdisciplinary team) members reviewed the care needs of (Resident #43) with (name of son) and a new plan of care will be done reflecting new changes in her care." A review of the care plan that was developed found the problems / strengths identified were in the following areas: Compromised short term memory, persistent episodes of anger manifested by her thinking that she does not need long term care, conflict with her family as demonstrated by her not being pleased with her placement, strong identification with past roles, as manifested by her believing she is capable of independent living, risk of low self-esteem as manifested by her admission to the facility, risk for falls, risk of side effects from antipsychotic medication use, and requiring assistance with personal hygiene tasks. There was no evidence of discussion of elopements or physical aggression and no evidence of the facility expressing concern to Resident #43's MPOA about the continued stay of Resident #43 at this facility. There were no other documented discussions or meetings with the family. - A review of social services notes found there was no note regarding the resident's transfer to the Behavioral Health Unit at the local hospital on [DATE]. There was a note dated 06/27/11 which stated: "Called and cancelled (Resident #43's) appointments with physical therapy this week." This was the final social services note in the medical record. A review of physician's progress notes found the last documented note was dated 06/15/11, and stated: "(Rt) (right) ear redness (illegible) tissue. Pressure related sleep changes." The nurses' note from that visit stated: "MD vs (visit) and examined right ear that was red and stated that it was pressure related from lying on the right side. Orders received to DC (discontinue) [MEDICATION NAME] at this time." There was no further documentation found by the attending physician. physician's orders [REDACTED].#43. It was explained by Employee #41 (a registered nurse assessment coordinator) that, since the electronic medical record was closed, all orders printed had "dc" at the beginning and " " at the end. The final physician's orders [REDACTED]." There were no further orders for permanent discharge from the facility. A discharge summary form, dated 07/13/11 and signed Employee #41, stated the resident was discharged to the local hospital. The course of treatment while in the nursing home was described as: "Alert, but confusion. Needs assist. Of one for all care to ensure optimum level of personal hygiene. Independent ambulation. Needed supervision to prevent resident from leaving facility property. Redirection for aggressive behavior." Pertinent diagnostic findings were described as "N/A" (not applicable). Essential information regarding illnesses or problems was described as: "Increased confusion, Redirection not always effective. Repeated attempts to leave facility + (and) facility property." Restorative procedures were described as: "Psyche consults medication adjustments." The section titled "Written discharge instructions given to" was not completed. The section for Physician Signature was blank. - The administrator, (Employee #2), DON (Employee #46), and social worker (Employee #34) all stated, during an interview of 08/02/11 at 3:00 p.m., that they had ongoing discussions with the family about their concerns for the safety of Resident #43 and their growing conviction that they could no longer ensure her safety as a resident of their facility. There was, however, no documentation to support that those exchanges occurred, and there was documentation that showed that both the Behavioral Health Unit at hospital and the family were clearly expecting the resident to be readmitted until the phone conversation of 07/11/11. The family was then required to make an unplanned admission to another nursing facility that provided the same level of care. - The record of Resident #43, whom the facility maintained was transferred / discharged due to safety reasons, did not reflect the process by which the facility concluded that transfer or discharge was necessary and did not contain evidence of accurate assessments and attempts through care planning to address resident's needs through multi-disciplinary interventions, accommodation of individual needs and attention to the resident's customary routines, and there was no documentation from the resident's physician that the resident was transferred / discharged for the sake of the resident's welfare and/or the resident's needs could not be met in the facility. . | 2014-12-01 |