| 3984 |
FAIRMONT HEALTHCARE AND REHABILITATION CENTER |
515189 |
130 KAUFMAN DRIVE |
FAIRMONT |
WV |
26554 |
2017-06-30 |
514 |
E |
0 |
1 |
25Q611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurately documented clinical records for each resident. Laboratory test results were absent in the chart for review for one (1) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Inventory of Personal Effects forms were blank and/or incomplete for four (4) of four (4) Stage 2 sample residents whose charts were reviewed during the QIS survey. In addition there were no education sheets for the yearly flu vaccinations and immunization consents for five (5) of five (5) sample residents reviewed for immunizations during the QIS survey. These findings had, the potential to affect more than an isolated number of residents. Resident identifiers: #80, #81, #14, #1, #52, #42, #123, #79, #26, and #34. Facility census: 115. Findings include: a) Resident #80 Medical record review on 06/29/17 at 8:15 a.m. found a physician's orders [REDACTED]. The HGBA1C results for 12/29/16 were not found in the resident's medical record. Registered Nurse (RN)/Nurse Educator #110 provided copies of the HGBA1C results for 12/29/16 on 06/29/17 at 10:30 a.m. She stated, I had to get them off of the computer because they were not in the chart where they are supposed to be located. Yes, they should have been in the chart because we do not have electronic records other than than the minimum data set (MDS). I agree it is an incomplete medical record because only the nurses have access to the chart and may not know to look there for the results. b) Inventory of Personal Effects forms On 06/28/17 at 10:31 a.m., during a medical record review for Resident #52 (who had missing glasses while in the facility) found her Inventory of Personal Effects form lacked signature of employee, signature of relative or resident and dates. Continued medical record reviews on 06/28/17 at 10:40 a.m. of Inventory of Personal Effects forms discovered the following: -- Resident #1's form lacked a signature of an employee, a signature of a relative or the resident, and dates. -- Resident #14's form lacked a signature of a relative or the resident. -- Resident #81's form was blank for personal effects and lacked a signature of a relative or the resident. On 06/28/17 at 2:12 p.m. Employee #28 explained the process for obtaining and completing the Inventory of Personal Effects form for residents. She stated, The nurse will give us the form when we go in to do vitals and weights to be filled out, signed and dated by the employee and the resident or family. After reviewing the Inventory of Personal Effects forms for Residents #52, #1, #14, and #81 on 06/28/17 at 3:15 p.m., the Assistant Director of Nursing (ADON) stated, Yes they are all incomplete medical records because they are to be signed and dated by the employee and signed by either the resident or family. She explained Resident #81's form was blank because she was not admitted with any personal effects, but stated, No one would know that by looking at the form. c) Review of medical records for Residents #79, #124, #34 #26, and #142, on 06/28/17 at 2:00 p.m., revealed all five (5) medical records lacked documentation/consent forms indicating the resident and/or the resident's legal representative consented for the influenza vaccine and/or received education regarding the current benefits and potential side effects prior to administration during the (YEAR)-2017 flu season. Resident #124 received the [MEDICATION NAME] flu vaccine on 10/11/16, Residents #79, #34, and #26 received the [MEDICATION NAME] vaccine on 10/12/16, and Resident #42 refused the vaccine in (YEAR). The Assistant Director of Nursing (ADON) provided copies of the Influenza (flu) consents for Residents #79, #124, #34, and #26 on the form titled Pneumococcal & Annual Influenza Vaccination Information & Request with a revision date of 02/2007, during an interview on 06/28/17 at 3:00 p.m. The ADON reported the consent forms were not kept in the medical records and acknowledged there were no other consents for the influenza vaccine or documentation related to annual education on the risks and benefits of the flu vaccine provided to the resident and/or family prior to the yearly administration of the flu vaccine. The Pneumococcal & Annual Influenza Vaccination Information & Request forms reviewed 06/28/17 at 3:10 p.m. and found to be incomplete were: -- Resident #79's consent was not dated or signed by the resident and/or responsible party or the facility representative. -- Resident #124's consent was signed on 10/05/16, but lacked identification of the person signing and a signature by the facility representative. -- Resident #34's consent was signed on 09/15/15 by a West Virginia Department of Health and Human Resources representative but lacked the signature of the facility's representative. -- Resident #26's consent was signed on 09/18/15 with no identification of the family member signing and lacked a signature of the facility representative. -- Resident #42's consent was signed on 09/14/15 by her daughter/health care surrogate but lacked a facility representative signature. Registered Nurse (RN) #109 and LPN #96 reviewed the consents for Residents #79, #124, #34, and #26 during an interview on 06/28/17 at 3:20 p.m. Both staff acknowledged the forms were incomplete lacking signatures and/or dates. RN #109 and LPN #96 confirmed the Pneumococcal & Annual Influenza Vaccination Information & Request form with a revision date was 02/2007 could not contain the current information from Centers for Disease Control and Prevention related to the benefits and potential side effects of the influenza vaccine. The facility failed to follow its policy titled Immunizations - Pneumococcal & Annual Influenza that stated, Counsel resident and/or family on the benefits and adverse effects by providing educational materials of each vaccine prior to administration of the vaccines. Section 4 of the guidelines included, Provide the resident and/or family with a copy of the applicable VIS (Vaccine Information Statement) .On an annual basis, the person administering the vaccine will Document the review of the VIS in the Nurse Progress Notes and include whom the VIS was given too. |
2020-04-01 |