cms_WV: 11477
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11477 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2010-10-14 | 280 | D | LTYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the care plan of one (1) of four (4) sampled residents was revised to reflect the resident's current problems and needs. The lack of an updated care plan resulted in a lack of goals and interventions to address the most current issues facing the resident. The facility had relocated the resident to a different area of the building in a room by himself, and the care plan failed to address this change in environment and the potential negative impact it could have on the resident. Resident identifier: #28. Facility census: 86. Findings include: a) Resident #28 Record review revealed a social work progress note documenting Resident #28's move to a room on second floor on 09/02/10, due to safety concerns surrounding his aggressive behaviors towards other residents. The resident had spent approximately ten (10) days in an inpatient acute psychiatric hospital from 08/03/10 through 08/13/10, due to increased aggressive behaviors. On 09/02/10, the facility moved Resident #28 to a semi-private room without a roommate on second floor, in order to ensure the safety of other residents and to monitor Resident #28's behavior. The facility also placed an alarm on a gate across the doorway which would sound when the resident came in and out of his room during the night time hours. Resident #28 came to the facility in February 2008. He had lived in a room on first floor with two (2) other roommates for over two (2) years. Due to his increased negative behaviors and the guardian's lack of acceptance of alternatives to promote the safety of the roommates (such as the use of a bed alarm on Resident #28 to alert staff when he was transferring out of bed), the facility elected to move the resident to ensure safety of others and to monitor for further agitation and negative behaviors. After the resident went to live on second floor, the facility failed to revised his care plan to address adjustment issues this resident faced. Resident #28 had [DIAGNOSES REDACTED]. He received [MEDICATION NAME] 0.5 mg twice a day for anxiety / agitation. He also received [MEDICATION NAME] 50 mg once a day for depression, as well as Mirtazepine ([MEDICATION NAME])[MEDICATION NAME](orally disintegrating tablets) 15 mg once a day at bedtime for depression. The care plan addressed specifics as to how the facility would monitor the resident's behavior to protect and ensure the safety of others. However, it failed to address the resident's relocation to a new environment and associated adjustment difficulties, especially in view of his pre-existing [DIAGNOSES REDACTED]. On 10/13/10, medical record review for Resident #28 revealed nursing staff had observed the resident talking to himself in his room on or near 09/29/10. The staff member identified this as a new behavior. Another staff member overheard the resident threatening to harm an incapacitated resident on 09/27/10. On 10/14/10 at approximately 4:00 p.m., the administrator and director of nursing confirmed the facility's interdisciplinary team had not addressed in the care plan how the move would impact the resident's psychosocial well-being. They agreed this was a significant life-changing event for someone with dementia, anxiety, and depression. They also agreed the care plan should have revised with goals, and interventions to assist the resident in reaching the goals, to promote the resident's highest practicable level of well-being. | 2014-02-01 |