cms_WV: 3928
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3928 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 411 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure dental services were obtained for one (1) of three (3) residents reviewed. The facility failed to obtain a surgical consultation with an oral surgeon as directed by the dentist, for a resident who received Medicare services. Resident identifier: #139. Facility census: 109. Findings include: b) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order, dated 04/25/16, for a consult with an oral surgeon for extraction of teeth, as recommended by the dentist. The physician services nursing facility subsequent visit form, dated 03/08/16, had noted the chief complaint/history record many damaged and non-restorable teeth. A physician's orders [REDACTED]. The dentist' assessment/plan included a referral to an oral surgeon for a full mouth extraction due to many damaged and non-restorable teeth, and was noted on 04/25/16. The medical record, reviewed from date of admission through 11/03/16 revealed a progress note dated 04/25/16 which noted the dentist assessed Resident #139 and the facility received an order to refer the resident to an oral surgeon for full mouth extraction. --04/28/16 - the resident saw the dentist and a recommendation was made to do a full mouth extraction; --04/30/16 - spoon feed all meals; --05/05/16 - waiting for an appointment for full mouth extraction; --06/30/16 - continue on [MEDICATION NAME] for mouth, resident is very hard to feed meals due to continually closing mouth; --07/07/16 - continue [MEDICATION NAME] to gums of mouth provided, when resident eating lunch because staff noticed resident crunching teeth, face getting red, and nurse provided with pain meds (medication) [MEDICATION NAME] 0.25 (milliliters) via mouth; --08/16/12 - a care plan meeting note was silent to dental issues. The family attended the meeting; and --09/07/16 - weight warning of a five percent (5%) weight loss over 30 days. No evidence was present in the electronic medical record or the paper record to indicate Resident #139 had received the consult with an oral surgeon. Nurse Aide (NA) #135, interviewed on 11/02/16 at 9:07 a.m., stated Resident #139 had dental pain, and staff used sponges for oral care. Licensed Practical Nurse (LPN) #64, present during the interview, and said the resident received [MEDICATION NAME] to the gums and teeth before meals for comfort and was now eating better. During an interview with Social Worker (SW) #54, on 11/02/16 at 11:06 a.m., the SW verbalized she had attended Resident #139's care plan meeting. The SW said the responsible party attended the meeting. When asked what was discussed with the family member, the social worker did not mention dental care. Upon inquiry, SW #54 said no evidence was present to indicate the facility had discussed the physician's orders [REDACTED]. The SW said the facility was looking for documentation. The census record indicated Resident #139 received Medicare services at the time of the order on 04/27/16 through 05/16/16. Scheduler #127, interviewed on 11/02/16 at 11:30 a.m., stated no evidence was present to indicate an appointment had been scheduled for the consult with the oral surgeon. A follow-up interview with the interim director of nursing (IDON) on 11/03/16 at 3:30 p.m. confirmed the facility failed to follow the physician's orders [REDACTED]. A dining observation, on 11/02/16 at 12:31 p.m., revealed Resident #139 received foods via a cup. The food was puree and a metal spoon was present on the tray. Upon inquiry, NA #69 said she did not use the spoon because it hurt the resident's teeth and she would turn her head away. NA #67 agreed and said Resident #139 received something for pain prior to meals. The medical director, requested an interview on 11/02/16 at 2:13 p.m., and said she wanted to address questions about Resident #139. The physician related she did not think the resident was a surgical candidate for a dental extraction and would not have had surgery. After explaining the appointment was for a surgical consultation, not surgery, the physician related she did not know why the appointment had not been made. Speech Therapist (ST) #31, on 11/02/16 at 3:50 p.m., said the administrator had requested she answer questions regarding Resident #139's dental care, refusal to eat and grinding of teeth. The ST said she had worked with the resident on admission to the facility and had related the grinding to [DIAGNOSES REDACTED] (inability to perform purposeful movements as a result of brain damage), not dental pain. When asked why the resident received [MEDICATION NAME] to her gums and teeth prior to meals if she did not have dental pain, the ST said she was not aware the resident received medication, and related she had not worked with Resident #139 in the last four (4) months. The ST note, dated 03/08/16 through 04/04/16 noted Resident #139 presented with clenched jaw and dental grinding especially during attempts at oral intake. Close jaw impaired; open jaw with resistance - impaired and again noted clenched jaw with dental grinding throughout the evaluation. The evaluation did not address dental pain. A follow-up interview with the interim DON on 11/03/16 at 3:30 p.m. confirmed the order had not been discontinued, no evidence was present to indicate the surgery had been contraindicated, no evidence the family had denied the consult, and verified the facility failed to follow the physician's orders [REDACTED]. | 2020-04-01 |