cms_WV: 3391
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3391 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 656 | D | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to develope and or implement care plans for three (3) of thirty-one (31) residents reviewed. For Resident #47 a care plan was not developed to include the Residents removal of her dressing after dailysis and her ablility to assess the [MEDICAL TREATMENT] after removal of the dressing. Resident #34's care plan did not include current information about advance directive. Resident #3's care plan was not implemented for dental care. Resident identifiers: #47, #34, and #3. Facility census: 108. Findings included: a) Resident #47 During an interview with the resident on 01/28/19 at 1:31 PM, regarding her [MEDICAL TREATMENT] treatment, the resident said she removes her own bandages to the fistula in the upper right arm. I don't want them (meaning the facility) to do it. I remove it after [MEDICAL TREATMENT] between 3:00 PM and 4:00 PM. The resident said sometimes she has some bleeding to the area. Observation of the residents' upper right arm found the dressing, placed by the [MEDICAL TREATMENT] center was still in place. The resident had received her [MEDICAL TREATMENT] treatment today. She said she has a 6:00 AM appointment every Monday, Wednesday and Friday. Medical record review found the resident receives [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] center, three (3) times a week on Monday, Wednesday, and Friday at 6:00 AM. Resident #47 was admitted to the facility on [DATE]. She has capacity to make her own medical decisions. The treatment administration record (TAR) found a current order for, (MONTH) remove dressing to right upper extremity at bedtime after [MEDICAL TREATMENT]. The order did not dictate who would remove the dressing. The (MONTH) 2019, TAR was never initialed on any days by any of the nursing staff. The resident is receiving [MEDICATION NAME] ([MEDICATION NAME]) 9 milligrams daily. [MEDICATION NAME] is a blood thinner that treats and prevents blood clots. On 01/29/19 at 4:09 PM, a second interview and observation of the resident found the bandage to the upper arm had been removed. The resident said she removed the dressing yesterday. At 4:12 PM on 01/29/19, the resident's Licensed Practical Nurse (LPN) #65, said, Usually she doesn't ask for the dressing to be removed. She will take it off herself. LPN #65 said the resident had never had any complications. On 01/29/19 at 4:22 PM, the Director of Nursing said, She can remove the dressing herself if care planned. The DON reviewed the care plan and confirmed the care plan did not include the anything about the resident removing her own dressing. Removal of the dressing, accessing the [MEDICAL TREATMENT] after removal, was not care planned. b) Resident #34 Review of Resident #34's comprehensive care plan revealed the following focus: Advance Directives Resident has been determined to have decision making capacity Resident has a DNR (do not resuscitate) order HCS (health care surrogate) on file for medical decision making On 04/16/17, Resident #34's physician signed a form that determined resident demonstrates incapacity to make medical decisions. During an interview on 01/29/19 at 3:56 PM, Registered Nurse (RN) #11 stated Resident 34's care plan was incorrect in stating resident had decision making capacity. During an interview on 01/29/19 at 4:20 PM, the Director of Nursing (DoN) was informed Resident #34's comprehensive care plan stated both that he had medical decision making capacity and also that he had a health care surrogate for medical decision making. The DoN was also informed that Resident #34 had physician documentation that he did not have medical decision making capacity. The DoN had no additional information regarding the matter. c) Resident #3 During an interview on 01/31/19 at 10:38 AM, Resident #3 stated that his teeth were infected. Resident #3 then opened his mouth to reveal that he was missing many teeth. Resident #3's remaining bottom row teeth appeared broken and discolored. Resident #3 stated that his bottom left tooth had been scratching his tongue and causing him pain. He also said that his dental problems were causing him to have difficulty with chewing food. He stated that he would like to keep his two (2) front teeth, but have the remaining teeth extracted due to his discomfort. He added that he had told staff about his dental discomfort, but the facility had not helped him obtain a dental consult. A review of Resident #3's care plan was conducted during the survey. The dental portion of the care plan revealed the following problem: Dental or oral cavity health problems related to possible carious teeth. The care plan goals associated with this problem were, Will be able to eat and drink free of pain, Will have no bleeding from gums, Will have no swelling/inflammation outcomes, and Will maintain good oral hygiene. Care plan interventions included the following: Refer to dentist/hygienist for evaluation/recommendations regarding denture realignment, new fitting, teeth extraction, repair of carious teeth, and Report changes in oral cavity, chewing ability, signs and symptoms of oral pain, etc. A review of Resident #3's Minimum Data Set (MDS) assessments was also conducted during the survey. Resident #3's annual MDS assessment with an Assessment Reference Date (ARD) of 07/14/18 had triggered the dental care portion of Section V, requiring a Care Area Assessment (CAA) to be completed by staff. The following description was written in the CAA for dental care: as noted from nursing assessment 7/18 resident states having issues with his teeth, this can lead to pain,infection wt (weight) loss and overall decline. During an interview on 01/31/19 at 11:23 AM, Registered Nurse (RN) #11 was asked if Resident #3 had ever had a dental consult. RN #11 said that Resident #3 had never complained about his teeth and that no dental consult had been obtained for him. The CAA information above was reviewed with RN #11. After reviewing the information, RN #11 said that she would look further for information regarding how the facility responded to this dental problem. Later on 01/31/19, RN #11 said that no dental consult had been obtained for Resident #3, but that she would address Resident #3's dental complaints that day. On 01/31/19 at 2:49 PM, the facility's Administrator was notified of the above information. She stated that Resident #3 had refused multiple dental appointments in the past, but that none of these refusals or facility attempts at making arrangements had been documented. | 2020-09-01 |