cms_WV: 11054
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
11054 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 386 | E | 0 | 1 | OJEL11 | Based on medical record review and staff interview, the facility failed to ensure the attending physician, for four (4) of twenty-eight (28) sampled residents, reviewed the resident's total plan of care with each assessment visit by signing routine and telephone orders. Resident identifiers: #15, #35, #19, and #4. Facility census: 128. Findings include: a) Resident #15 The medical record of Resident #15, when reviewed on 06/23/09, disclosed the resident's attending physician wrote a progress note describing a regular assessment visit for this resident on 05/29/09. Further review disclosed the physician had failed to sign telephone orders given to facility staff on 01/10/09, 01/29/09, 04/03/09, 04/08/09, 04/15/09, 04/24/09, 04/28/09, 05/06/09, 05/08/09, and 05/12/09. This information was presented to the facility's director of nursing (DON - Employee #82) on 06/23/09 at 11:00 a.m., and she confirmed the physician should have signed and dated these outstanding orders. b) Resident #35 Medical record review, completed on 06/23/09, revealed the physician was in the facility and saw Resident #35 on 06/19/09. Further record review revealed telephone orders received prior to this visit which the physician did not sign, which had been given on 06/03/09, 06/08/09, 06/13/09, and 06/15/09. On the afternoon of 06/25/09, the DON, when interviewed, identified the physician recently came to her and told her he thought he was caught up with all documentation. The DON acknowledged at this time he must not be caught up with all the documentation. c) Resident #19 A review of the clinical record revealed verbal orders from the physician of Resident #19, given on 05/19/09, had not been signed by the physician as of 06/24/09, although he had visited the resident and had written a progress note on 06/05/09. During an interview with the administrator at 10:30 a.m. on 06/25/09, he acknowledged it appeared the physician had overlooked some of the orders. d) Resident #4 This resident had ten (10) telephone orders which had not been signed when the physician made his last visit on 06/22/09. These telephone orders were dated 05/23/09, 05/24/09, 05/27/09, 06/02/09, 06/03/09 (two (2) orders), 06/04/09, 06/07/09, 06/12/09, and 06/16/09. . | 2014-09-01 |