cms_WV: 120
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 120 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 280 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, family interview and resident interview the facility failed to ensure four (4) of twenty-nine (29) residents whose care plans were reviewed had care plans that were revised as the resident's needs changed. The facility failed to revise Resident #59's care plan in the area of incontinence, Resident #84's care plan was not revised in the area of nutritional status, Resident #284's care plan was not revised in the area of accidents after a resident experienced three (3) falls, and Resident #286's care plan in the area of discharge planning. Additionally, Resident 19's responsible party was not given enough notice to attend care plan meetings. Resident identifiers: #59, #84, #284, #286 and #19 Facility census: 180. Findings include: a) Resident #59 The Minimum Data Set (MDS) review for Resident #59 indicated this resident was assessed as occasionally incontinent on the admission MDS. On the quarterly MDS, completed on 06/02/17, this resident was assessed as frequently incontinent. The care plan review revealed a focus area of occasional incontinence. This focus area was initiated on 03/27/17. The goal for the resident to be continent at all times was revised on 04/18/17 with a target date of 07/17/17. During an interview on 09/07/17 at 10:21 a.m. with Registered Nurse/MDS #46 she confirmed the resident's care plan was not revised to show the resident's decline from occasional to frequent incontinence. b) Resident #84 The medical record review for Resident #84 revealed a weight loss between the dates of 07/11/17 and 08/15/17. The resident weighed 207 pounds (lbs) on 07/11/17 and 180 lbs on 08/15/17. While in the hospital on [DATE] a weight was recorded as 187 lbs. The care plan dated 08/05/17 stated Resident #84 was at nutritional risk related to history of therapeutic diet, [MEDICAL CONDITIONS], hypertension, wound, [MEDICAL CONDITION] and abnormal labs. On 07/11/17 the physician ordered [MEDICATION NAME] 20 milligram (mg) every day for 3 days due to [MEDICAL CONDITION]. On 07/20/17 the physician ordered [MEDICATION NAME] 20 mg once a day for three days due to [MEDICAL CONDITION]. On 08/02/17 the physician ordered [MEDICATION NAME] 40 mg for five (5) days once a day for [MEDICAL CONDITION]. The nurse practitioner had indicated the resident had [MEDICAL CONDITION] on 06/29/17, 07/07/27, 07/24/17, 08/01/17 and on 08/04/17 the [MEDICAL CONDITION] was noted as stable. On 09/05/2017 at 2:56 p.m. during an interview with Registered Dietician (RD) #181 regarding the resident's nutritional care plan, RD #181 agreed the plan for nutrition did not take into account that the residents' weight fluctuations could be related to [MEDICAL CONDITION]. In a progress note from the dietician dated 09/06/17, the dietician indicated the resident's weight loss could be multi-factorial due to increased [MEDICATION NAME] due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. c) Resident #284 Resident #284 was originally admitted to the facility on [DATE], and was discharged on [DATE]. Care planning related to a risk for falls was initiated on 03/29/17. Resident #284 was readmitted to the facility on [DATE]. The care plan goal revised on 06/20/17 was (Resident #284) will be free of falls through the review date. The care plan focus revised on 06/22/17 was (Resident #284) is at risk for falls related to impaired cognition, muscle weakness, impaired balance, wounds. On 07/30/17 at 7:45 p.m., Resident #284 was found lying face first on the floor beside his bed. He suffered an abrasion to his left forearm and a skin tear to his right hand. On 07/31/17, bilateral floor mats at all times were ordered. An updated care plan intervention for bilateral floor mats was also initiated on 07/31/17. On 08/01/17 at 5:00 a.m., Resident #284 was again found lying on the floor next his bed. A small circular skin tear was noted to his left great toe. On 09/0517 at 5:34 a.m., Resident #284 was again found lying on the floor next to his bed. No injury was noted. Resident #284's care plan focus and goal were not updated after he experienced three (3) falls. During an interview on 09/06/2017 at 4:06 p.m., the Director of Nursing (DON) had no additional information about the care plan not being updated to reflect that Resident #284 had experienced falls. On 09/06/17, after the DoN had been interviewed, the care plan focus related to falls was updated to (Resident #284) has experienced a fall and is expected to experience further falls related to impaired mobility, impaired cognition, poor safety awareness and history of falls. The goal was updated to (Resident #284) will be free of injury as a result of fall through next review period. d) Resident #286 Review of the resident's admission minimum data set (MDS) with an assessment reference date (ARD) of 4/26/17 noted the resident participated in his care plan and expected to be discharged to the community. According to the MDS active discharge planning was occurring for the resident to return to the community. Review of the current care plan found the following problem: (Name of Resident) wishes to return home to his trailer at discharge however his HCS (Health Care Surrogate) would like possible long term placement. The goal associated with the problem: (Name of Resident) will be able to verbalize required assistance post-discharge and the services required to meet needs before discharge. Interventions included: Establish a pre-discharge plan with the resident/family/caregiver and evaluate progress and revisit plan as needed. Evaluate the resident's motivation to return to the community. At 2:26 p.m. on 09/05/17, Employee #77 (social worker) said the resident had to re-gain capacity before going home. She verified the care plan did not entail the steps the resident needed to take to complete his discharge to home. She could provide no evidence the care plan was updated with a specific pre-discharge plan. e) Resident #19 A family interview with the resident's responsible party, by telephone, at 9:43 a.m. on 08/29/17, found the facility provided, short notice, for care plan attendance. The responsible party said she needed at least a 2 week notice or more to be able to schedule time away from work to attend the care plans. Review of the paper medical record at 9:05 a.m. on 08/30/17, found the following invitations to care plan meetings for Resident #19: March 28, (YEAR) at 11:15 a.m. April 18, (YEAR) at 10:00 a.m. June 15, (YEAR) at 11:15 a.m. August 15, (YEAR) at 1:00 p.m. Each invitation letter was a form letter, containing the following information, A care plan conference will be held for (Name of Resident) (date and time). This time has been set aside to review the plan of care being provided by our facility. Please inform the Resident Care Management Department at least one day prior to the above scheduled time if you plan to attend. If you are unable to attend and would like a phone conference, please call and schedule. Thank you, The resident care management department Each letter contained the same information and did not indicate to whom the letter was mailed, or the date the invitation was generated. Upon interview, on 8/30/17 at 9:05 a.m., Employee #133, the minimum data set (MDS) coordinator, said she was in charge of mailing the care plan invitations . She could not provide documentation to verify when the care plan letter was actually mailed. She stated, If she would have called I could re-schedule. The letter says if you are unable to attend and would like a phone conference to please call. The Responsible party said she wanted to attend the care plan in person but did not have time to schedule time away from work. At 9:55 a.m. on 08/30/17, [NAME] #133 confirmed she had no way to verify when the care plan letter was actually mailed to the responsible party. c) Resident #284 Resident #284 was originally admitted to the facility on [DATE], and was discharged on [DATE]. Care planning related to a risk for falls was initiated on 03/29/17. Resident #284 was readmitted to the facility on [DATE]. The care plan goal revised on 06/20/17 was (Resident #284) will be free of falls through the review date. The care plan focus revised on 06/22/17 was (Resident #284) is at risk for falls related to impaired cognition, muscle weakness, impaired balance, wounds. On 07/30/17 at 7:45 p.m., Resident #284 was found lying face first on the floor beside his bed. He suffered an abrasion to his left forearm and a skin tear to his right hand. On 07/31/17, bilateral floor mats at all times were ordered. An updated care plan intervention for bilateral floor mats was also initiated on 07/31/17. On 08/01/17 at 5:00 a.m., Resident #284 was again found lying on the floor next his bed. A small circular skin tear was noted to his left great toe. On 09/0517 at 5:34 a.m., Resident #284 was again found lying on the floor next to his bed. No injury was noted. Resident #284's care plan focus and goal were not updated after he experienced three (3) falls. During an interview on 09/06/2017 at 4:06 p.m., the Director of Nursing (DoN) had no additional information about the care plan not being updated to reflect that Resident #284 had experienced falls. On 09/06/17, after the DoN had been interviewed, the care plan focus related to falls was updated to (Resident #284) has experienced a fall and is expected to experience further falls related to impaired mobility, impaired cognition, poor safety awareness and history of falls. The goal was updated to (Resident #284) will be free of injury as a result of fall through next review period. | 2020-09-01 |