cms_WV: 195
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 195 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2019-04-11 | 656 | D | 0 | 1 | M7ZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview, and staff interview, the facility failed to develop a care plan to include the contact information of a resident's Hospice service provider; and implement care plan interventions related to oxygen therapy, positioning, and skin integrity. This was true for three (3) of fourteen (14) resident care plans reviewed during the annual long-term care survey process. This practice had the potential to affect more than a limited number of residents. Resident identifier: #2, #17, and #1. Facility census: 39. Findings included: a) Resident #2 (R#2) Review of records revealed R#2 was admitted to Hospice services on 07/09/18 and was admitted to the facility on [DATE]. Review of R#2's care plan, on 04/10/19 at 2:54 PM, revealed the Hospice 24-hour contact information was not included in the care plan. An interview, on 04/10/19 at 3:50 PM with the MDS nurse responsible for developing resident care plans, confirmed R#2 care plan was developed without including the Hospice 24-hour contact information. The MDS nurse said the resident already had Hospice services when she came to the facility, and the Hospice 24-hour contact information should have been included when the facility first developed the resident's care plan. The MDS nurse stated she would update the care plan now with the Hospice 24-hour contact information. b) Resident #17 (R#17) Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) 02/18/19, on 04/10/19 at 09:46 AM, revealed the resident has clear speech, makes them self-understood and understands. The resident's Brief Interview for Mental Status (BIMS) score was twelve (12) indicating the resident is moderately impaired. R#17 did not exhibit any behaviors. The resident is totally dependent with bed mobility, meaning full staff performance every time. The resident needs supervision with eating and is totally dependent with all other activities of daily living (ADLs). ADLs include bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident has impairment in both lower extremities. Some [DIAGNOSES REDACTED]. 1. Oxygen Review of R#17's care plan, on 04/10/19 at 10:28 AM, revealed the resident has chest pain related to [MEDICAL CONDITION] with an intervention: Oxygen (02) via nasal prongs as ordered. Observations, on 04/10/19 at 8:44 AM, revealed resident's oxygen flow meter was set close to 4L (liters per minute). Review of the current orders revealed, oxygen at 2L per nasal cannula continuous related to decrease O2 sats (blood oxygen saturation). On 04/10/19 at 9:01 AM, Registered Nurse (RN#91) and RN#3 entered resident #17's room. This surveyor requested RN#91 look at the oxygen meter to see what rate the flow meter was on. RN#91 stated the 02 was on 3 1/2L, confirming the oxygen rate was not 2L as was ordered and indicated in the care plan. RN#91 adjusted the resident's oxygen rate to 2L as ordered and care planned. 2. Positioning Review of R#17's care plan, on 04/10/19 at 10:28 AM, revealed the resident has an activities of daily living (ADL) self-care performance deficit. Two of the interventions include, Bed mobility: The resident requires extensive to total assistance with repositioning at all times. Transfer: The resident requires Hoyer lift and is dependent on 2 staff for transfer. On 04/08/19 at 12:35 PM, during an interview with the resident, restorative nurse aide (NA#61) entered the room with the resident's lunch tray and sat it on the over bed table. opened items for the resident on the tray, placed butter on the resident's potatoes, NA#61 assisted the resident with her napkin, raised the head of the resident's bed to about seventy five (75) degrees from (45) degrees, and pleasantly ask the resident if there was anything else she wanted, then left the room. Before leaving the nurse aide did not check to make sure the resident could reach items on her tray, or if R#17 was positioned comfortably and/or in good body alignment to facilitate eating. R#17 was lying low in the bed before NA#61 raised the head of the bed. However, when the nurse aide raised the head of the bed the resident slid down even more into the bed. The resident's lower back was curved and raised off the bed surface unsupported in the bend of the bed. The resident's upper torso was hunched over and her chin pointed down to her neck. R#17 struggled to reach the items on her lunch tray. The resident's body positioning was poorly aligned and did not facilitate affective swallowing. This surveyor asked the resident, Are you comfortable? The resident replied, No, I'm not comfortable! This surveyor asked the resident if she could straighten her own self up in the bed, and R#17 answered, No, I can't do it, I need help. This surveyor requested the resident use her call light to get assistance to help straighten her up in the bed. NA#61 answered the call light, and agreed the resident needed pulled up in the bed and repositioned. NA#61 left the room and returned with NA#2 to assist in repositioning the resident in her bed after surveyor intervention. c) Resident #1 Review of Resident #1's medical records revealed the resident had a skin tear on her coccyx, a skin tear on her foot, and a deep tissue injury on her left hip. Weekly wound assessments of the skin tear on the foot and the deep tissue injury on the hip had been documented in the progress notes and on a wound weekly observation tool. The skin tear on the coccyx was first observed on 03/26/19 and the wound was measured as 5 cm x 2.5 cm at that time. No further assessments of the coccyx skin tear could be located in the medical records. Resident #1's comprehensive care plan contained the focus, I have a potential for impairment to skin integrity r/t (related to) fragile skin. The interventions included, I will have weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Resident #1 had an order for [REDACTED]. Sure Site is a transparent dressing used to protect a wound while it heals. On 04/11/19 at 10:30 AM, Assistant Director of Nursing (ADoN) #23 was observed changing Resident #1's coccyx Sure Site dressing. ADoN #23 stated she was going to have the physician assess Resident #1's coccyx skin tear to determine if a different treatment and dressing would be beneficial. Resident #1's coccyx wound was addressed in the following progress notes: (The notes are typed as written.) - 03/26/19 at 6:50 PM: Skin tear remains suresite C/D/I (Clean, dry, intact) . - 3/27/19 at 3:04 AM: Skin tear suresite C/D/I . - 03/27/19 at 11:30 AM: Resident with skin tear to her coccyx. Sure site is CDI . - 03/28/19 at 6:25 PM: .Skin tear remains to coccyx . - 03/29/19 at 7:50 PM: .Skin tear remains to coccyx . - 03/30/19 at 5:09 AM: Skin tear remains to coccyx . - 03/30/19 at 6:51 PM: .Skin tear remains to coccyx . - 03/31/19 at 2:44 AM: .Skin tear remains to coccyx . - 04/02/19 at 2:53 AM: .Skin tear remains to coccyx . - 04/03/19 at 1:11 AM: .Skin tear remains to coccyx . - 04/06/19 at 12:37 AM: .Skin tear remains to coccyx . During an interview on 04/11/19 at 1:05 PM, the Director of Nursing (DoN) stated she was unable to locate updated assessments of Resident #1's coccyx skin tear. The DoN stated skin tears do not require assessments on the wound weekly observation tool. During an interview on 04/11/19 at 1:56 PM, the Administrator and Director of Nursing were informed the facility failed to implement Resident #1's comprehensive care plan intervention to perform weekly treatment documentation including measurement of each area of skin breakdown. The Administrator and Director of Nursing had no further information regarding the matter. No information was provided through the completion of the survey. | 2020-09-01 |