cms_WV: 3985
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3985 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 520 | F | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, resident interviews, confidential staff interviews, and confidential resident interviews, and review of Quality Assurance and Assessment (QA&A) Committee sign-in sheets, the facility failed to identify and/or correct quality deficiencies of which they were aware, or should have been aware. These deficient practices included failure to ensure prompt efforts to resolve concern/grievances in a timely manner, failure to maintain residents' dignity with proper positions during dining, failure to maintain a clean comfortable homelike environment in the dining room and ensuring used wash cloths with feces are not left in a resident room, failure to provide housekeeping and maintenance services to maintain a sanitary orderly and comfortable interior by repairing and/or replacing cosmetic imperfections in hallways and resident rooms, to maintain hallways that are free of accident hazards by repairing or replacing electric baseboard heaters in main hallways, failure to provide yearly education prior to the administration of the influenza vaccine, to maintain an effective infection control program and to maintain complete and accurate medical records. These practices have the potential to affect all residents residing in the facility. Facility census: 115. Citation Text for Tag 0520, Regulation FF10 [NAME], [NAME] [NAME], [NAME] [NAME] Based on observation, staff interviews, resident interviews, confidential staff interviews, and confidential resident interviews, and review of Quality Assurance and Assessment (QA&A) Committee sign-in sheets, the facility failed to identify and/or correct quality deficiencies of which they were aware, or should have been aware. These deficient practices included failure to ensure prompt efforts to resolve concern/grievances in a timely manner, failure to maintain residents' dignity with proper positions during dining, failure to maintain a clean comfortable homelike environment in the dining room and ensuring used washcloths with feces are not left in a resident room, failure to provide housekeeping and maintenance services to maintain a sanitary orderly and comfortable interior by repairing and/or replacing cosmetic imperfections in hallways and resident rooms, to maintain hallways that are free of accident hazards by repairing or replacing electric baseboard heaters in main hallways, failure to provide yearly education prior to the administration of the influenza vaccine, to maintain an effective infection control program and to maintain complete and accurate medical records. These practices had the potential to affect all residents residing in the facility. Facility census: 115. Findings include: a) Resolution of concerns/grievances 1. Resident #1 On 06/22/17 at 11:38 a.m., Resident #1's responsible party was interviewed in the resident's room. She was surprised her mother was still in bed. She had two large cups for the resident's water, which were not filled. She was taking the cups to the administrator to make a complaint. Updated complaint/grievance forms were requested regularly as the survey progressed. As of the final day of the survey on 6/30/17, there was no complaint form regarding the lack of water for hydration. On 06/27/17 at 9:10 a.m., a visit was again made to Resident #1's room. Nurse Aide #64 was in the room cleaning an area of the floor between the bed and the bathroom door. She said she had been called to the room by the resident's responsible party because there was feces on the washcloth and the floor. She said she was not the one who had left it there, but she was cleaning it up. The responsible party entered the room and said she had found the mess on the floor when she arrived for her visit and since there was no one around, she had gone in search of someone to clean it up. On 6/29/17 at 10:00 a.m., Resident #1's responsible party was interviewed in the resident's room. She said she had gone to interrupt the management morning meeting on 06/27/17 to make a complaint about the feces filled washcloth on the floor. Updated complaint/grievance forms were requested regularly as the survey progressed. As of the final day of the survey on 6/30/17, there was no complaint form regarding the feces on the washcloth on the floor. She again held the large cups in her hands. The cups contained some ice in them, but no water. She said she had complained about the water just a few days ago, but it did no good. Review of the Resident council meeting minutes for the previous six (6) months on 06/21/17 at 4:00 p.m. found the minutes recorded on a form called Resident Council Quality of Life Assessment - Group Interview. Some of the months, the form had two pages, and for others, there were three. Not all the questions had responses noted. For those that did, some negative responses were found as follows: -- For the 06/05/17 meeting, for the question, Does the group have input into the rules of the facility? the response was No, because they always give you reason for the rules. The question Does the facility listen to your suggestions? was answered Sometimes. The question Are there places you can go when you want to be with other residents? was answered Not really, need more places. -- For the 05/05/17 meeting, for the question Does the group have input into the rules of the facility? the response was No. The question Does the facility listen to your suggestions? was answered Sometimes. The question Are there places you can go when you want to be with other residents? was answered No. The question Are the temperatures of your foods ok? was answered Sometimes. The question How did staff react? (to a voiced grievance/concern) was answered They listened, but it depends on who it is. -- For the (MONTH) (YEAR) meeting (no specific date was on the minutes), for the question Does the group have input into the rules of the facility? the response was No. The question Are meals generally on time? was answered No. -- For the 03/01/17 meeting, the question Is there enough staff to take care of everyone? the answer was No. There was no list of attendees for the May, June, or (MONTH) (YEAR) meetings. For the January, February, and (MONTH) (YEAR) meetings, the average attendance was twenty-two (22) residents. There was no evidence of any attempts by the facility to address these negative responses. There was no follow up noted in the meeting minutes, and there were no complaint/grievance forms corresponding to the dates the concerns were stated by the council. On 06/29/17 at 10:00 a.m., during an interview, Activities Director #140 agreed there was no record of any resolution or any attempt to address the concerns voiced by the council. On the afternoon of 06/28/17, Administrator #135 said the facility had a Concierge Program to compliment the complaint/grievance policy and procedure. She said residents and families were told about the program upon admission. The administrator said management staff were assigned a group of resident rooms and were charged with completing rounds at least weekly which were to be documented on a form entitled Concierge Program Rounds. Review of the policy and procedure found the concierge was charged with assisting the resident to complete a complaint/grievance form if needed. Review of some of the completed rounds found a form dated 06/12/17 in which an assigned management person for room [ROOM NUMBER]-1 checked the box on the form that Concern Completed: Resident is making a statement which indicates his/her needs are not met. As of the final day of the survey, there was no completed complaint/grievance form found to document the concern. The responsible party for Resident #1 was asked about the concierge program as a possible means of resolving grievances on 06/29/17 at 9:30 a.m., she said she had never heard of it. 2. Resident #52 On 06/26/17 at 12:16 p.m., during a Stage 1 family interview, when asked, Has (resident's name) had any missing personal items? the resident's daughter answered Yes, they have lost my Mother's glasses months ago. A review of the concern/grievance reports, on 06/28/17 at 2:30 p.m., found a concern/grievance report dated 04/04/17 by Resident #52's daughter was reported to Referral Manager/Social Worker (RM/SW). Under title of Documentation of Grievance/Complaint, the concern was described as (typed as written): Said her mothers glasses have been missing and no one followed up with her about this. Also (first name of Resident #52) hair was dirty and a dirty blanket on dresser and teeth not clean, commode not flushed. Under Documentation of Facility Follow-up, was Individual designated to take action on this concern: (name of Assistant Director of Nursing (ADON)), and a date resolved by of 04/06/17. Also noted was, Involved staff members were in-serviced on above concern. Follow-up reveals compliance with care concerns. Under Resolution of Grievance/complaint, a check mark was placed before Yes and written documentation stated (typed as written), NHA (Nursing Home Administrator) on porch discussing with daughter and when staff came to get her to clean her up better and do her teeth, the daughter refused and said not now. Staff did complete after daughter left. This form was signed by the NHA on 04/24/17. During an interview, and after reviewing the concern/grievance form for Resident #52, on 06/28/17 at 3:38 p.m., RM/SW explained, I just took the concern and the NHA follows up on that and determines whether it is resolved or not. On 06/28/17 at 3:42 p.m., after reviewing the concern/grievance form for Resident #52, the NHA agreed that it was not resolved. She stated, I just spoke with the daughter about this and she said her mother has not had her glasses for over 2 months, but I told her I thought they were found because I just put a pair of glasses on her last week. I remember because I had to fix her bangs when I put the glasses on. When asked about the time frame for resolution of concerns, she stated it took more than 1 or 2 days because they look through laundry and everything. When further inquired whether it should take more than two (2) and a half (1/2) months to resolve a concern since this concern was voiced on 04/04/17 and Resident #52's glasses were still missing, she stated, Well they might be in the nurses' cart. On 06/28/17 at 3:52 p.m., the NHA, with a glasses case in her hand, showed a pair of glasses reported, These are the glasses that were in the drawer at the nurses' station that she (Resident #52) wore last week, but they aren't hers (Resident #52). The daughter described hers (Resident #52) as black with gold squiggly things at the temple and these are just plain brown. So, we will have to just keep looking. When asked again about a time frame for resolution of a resident's or family member's concern/grievance, the NHA did not reply. b) The facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. A random observation found staff did not clean a mechanical lift removed from the soiled utility room (where it was stored) before or after use to transfer a resident. An uncovered toilet plunger sat on the floor beside the toilet in a common resident bathroom. In addition, a washcloth with feces lay on the floor in a resident's room. 1. Resident #71 Observations on 06/29/17 at 9:09 a.m. noted Employee #R removed a mechanical lift (Hoyer lift) from the soiled utility room on the North unit - 400 hall without sanitizing the equipment. She proceeded down the hallway to Resident #71's room and with the assistance of Employee #O, utilized the mechanical lift to transfer Resident #71 from his bed to his wheelchair. The mechanical lift was taken back to the soiled utility room without sanitizing the equipment. Immediately following this observation during a confidential interview with Employee #R, she verified the mechanical lift was not properly sanitized before or after the transfer of Resident #71. Employee #R stated, The lifts are always kept in soiled utility room and they (mechanical lift) are never cleaned by any staff before or after used to transfer residents. I didn't know we were supposed to clean them and even if we wanted to there is nothing to clean them with. (First name of Housekeeping Supervisor) never leaves us anything to clean them with. Employee #O, present during the previous confidential interview verified the lift was not cleaned after removing from soiled utility room or before the transfer of Resident #71. She stated, No we have never cleaned anything before or after we use it nobody does, even if we wanted to there is nothing for us to clean it with. I can tell you none of the staff in this facility on any shift ever clean the lift. Infection Control Nurse #102 reported on 06/29/17 at 11:00 a.m., There are cleaning wipes stored in the medication room and the nurses have the keys, but had to look for a while to find them. We keep them under lock and key now because of the last survey, and no, the aides don't have access unless they ask the nurse for them. We are limited with storage areas, but the soiled utility room is the worst place to store the mechanical lifts and they should be sanitized before and after using as is our policy and standards of care. 2. The initial tour on 06/21/17 at 4:30 p.m., accompanied by Unit Manager #97, found an uncovered toilet plunger sitting beside the toilet of the common restroom utilized by residents on South unit-200 hall. She stated, The plunger is supposed to be covered not sitting directly on the floor. Yes, it is an infection control issue because it is used to unplug the toilet. 3. Resident #1 On 06/27/17 at 9:10 a.m., a visit to Resident #1's room found Nurse Aide #64 in the room cleaning an area of the floor between the resident's bed and the bathroom door. She said she had been called to the room by the responsible party because there was feces on a washcloth and the floor. She said she was not the one who had left it there, but she was cleaning it up. The responsible party entered the room and said she had found the mess on the floor when she arrived for her visit and since there was no one around, she had gone in search of someone to clean it up. b) The facility failed to ensure the residents' environment remained as free of accident hazards as is possible. Electric baseboard heaters in the main hallways had sharp corner edges where they were mangled and bent. The main hallways on the North and South sides were utilized as main thoroughfares by residents. Observations during the initial tour of the facility on 06/21/17 at 4:30 p.m., found the electric baseboard heaters in the main hallways were mangled and bent with sharp corner edges. There were three (3) baseboard heaters on the 200 hall, two (2) on the 100 hallway, three (3) on the 300 hallway, and two (2) on the 400 hallway. When observed on 06/21/17 at 5:00 p.m. accompanied by the Maintenance Director, he stated, Those baseboard heaters are not used. I just need to remove them and repair the baseboards. Yes, the baseboard heaters look bad in the hallways and with those sharp edges could certainly be an accident hazard because someone could scratch or cut themselves on those corners. c) Housekeeping and Maintenance The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, clean and comfortable homelike interior. Bathroom sink cabinets were chipped and broken and the interiors were stained and discolored. Faucets were dripping and sink drains were rusted or broken. Insulation was hanging below the front sink edge and caulking was cracked or missing around the sinks and toilets. Cove molding was loose and damaged in the bathrooms and vinyl bathroom floors were cracked. Bathroom mirror facings were chipped along the bottom edge. The central bathrooms on the 200 and 300 halls were cluttered with resident equipment and supplies. Wall heaters on the North and South ends of the building were rusted and floor base heaters on the 100, 200, and 300 halls were in disrepair with mangled sharp edges, loose parts, and large dust particles inside. 1. Observation of the facility during Stage 1 and Stage 2 of the Quality Indicator Survey revealed the following rooms had environmental concerns and cosmetic imperfections. a. room [ROOM NUMBER] The sink faucet was constantly dripping, the cove molding on the side of the commode was easily pushed in and there was dirt and grime accumulation in the corner of the bathroom door. b. room [ROOM NUMBER] The caulking was stained and discolored around the commode and the cove molding was not secured to the wall on the right side of the toilet. c. room [ROOM NUMBER] The sink cabinet was chipped and in disrepair and the floor was stained and discolored around the toilet base. d. room [ROOM NUMBER] The left side of the board on the bottom of the sink cabinet was dislodged and resting on the floor. The right cabinet face panel was loose and slid easily to the side. The plaster was off the exterior wall corner next to the sink exposing the metal support which was leaning out. e. room [ROOM NUMBER] The bathroom mirror facing was missing along the edge. The sink faucet was dripping and the cabinet had multiple areas of chipped particle board. The caulking was cracked around the sink top and missing around the commode, and the cove molding was loose and leaning outward below the sink. f. room [ROOM NUMBER] The foam insulation was hanging out the front edge of the bathroom sink. The edges of the particle board sink cabinet were rough and bare and the inside bottom shelf was stained and discolored. g. room [ROOM NUMBER] The bathroom sink cabinet was chipped along the lower edges of the doors and there was no caulking around the commode. h. room [ROOM NUMBER] The bathroom sink caulking was cracked, the cabinet doors were chipped, and the bottom shelf on the inside of the cabinet was split, swollen and in disrepair. i. room [ROOM NUMBER] The bathroom sink drain plug was rusted and there were holes in the cabinet from improper assembly of the front panel coverings. j. room [ROOM NUMBER] The bathroom sink cabinet was missing a front panel leaving a large square hole and the inside bottom shelf was wavy from moisture damage. h. room [ROOM NUMBER] The bottom shelf inside the bathroom sink was wavy and discolored and the vinyl floor was cracked on both sides of the toilet. e. room [ROOM NUMBER] The inside bottom of the bathroom sink was wavy and the vinyl floor contained a linear crack on the left side of the commode. f. room [ROOM NUMBER] The bathroom sink drain top was broken off. During a tour of the facility with the maintenance supervisor on 06/28/17 at 10:35 a.m., he agreed these items needed repaired and/or replaced. He stated he could easily fix the dripping faucets and the drain plug, but did not have the supplies to replace the sink cabinets or replace the bathroom floors. 2. Central bathrooms Observations of the central bathrooms on the 200 and 300 halls during the initial tour on 06/21/17 at 4:30 p.m., and randomly throughout the survey found both restrooms were used by residents while stocked with supplies and equipment. The North restroom located on the 300 hall contained a sink by the door and a commode in the far corner across from the door. Next to the commode was a curtain touching an empty chart rack. Beside the chart rack in the far left corner were 180 gallons of water in plastic jugs with an open plastic cover across the top and sides. Beside the water along the wall were shelves stocked with briefs and other supplies. In addition, two (2) wound carts with treatment records, a suction machine, the emergency crash cart, a wheelchair scale, and multiple supplies including a mattress. Licensed Practical Nurse (LPN) #112 accompanied the surveyor into the restroom during the initial tour and acknowledged the residents use both the 300 hall and 400 hall restrooms. LPN #112, reported the facility used the water for emergency situations, the chart rack next to the toilet was used by the facility, and the mattress and other supplies near the door were waiting to be returned to someone. The south restroom located on the 200 hall was also used by the residents and storage of resident equipment and supplies. A tour of the 200 hall restroom on 06/28/17 at 10:35 a.m. found the following items: a wheelchair scale and a stand-up scale, two (2) unlocked wound care carts with the treatment records on top, a mop and bucket of water, a chart rack, 180 gallons of water in plastic jugs, several packages of briefs, a crash cart, and several lift blankets. On 06/21/17 at 4:50 p.m., during the initial tour, Unit Manager/RN #97 reported there was no other place to store the carts and acknowledged this could be an infection control issue since the bathroom was used by the residents on all three (3) shifts. Confidential interviews with Employee A and Employee B during the survey confirmed the central restrooms on the 200 and 300 halls were used by the residents on all three (3) shifts. The employees stated that independent residents were left unattended in the restroom/storage space on the 200 and 300 halls. 3. The initial tour of the facility on 06/21/17 at 4:30 p.m., discovered in the main hallways by exit doors on 100, 200, 300 and 400 hallways, wall heating units with rusted vents. Electric baseboard heaters in the main hallways were mangled and bent, with sharp corner edges. These halls were utilized as a main thoroughfare by residents. There were three (3) baseboard heaters on the 200 hall, two (2) on the 100 hallway, three (3) on the 300 hallway, and two (2) on the 400 hallway. On 06/21/17 at 5:00 p.m., accompanied by the Maintenance Director, the baseboard heaters were viewed again. He stated, Those baseboard heaters are not used I just need to remove them and repair the baseboards. The wall unit vents need painted. Yes, the baseboard heaters look bad in the hallways and with those sharp edges could certainly an accident hazard. d) The facility failed to educate each resident and/or the resident's legal representative on the benefits and potential side effects of the influenza vaccine prior to administering the vaccine during the current (YEAR)-2017 flu season. In addition, the consent forms presented on admission were not updated to reflect the CDC's current vaccine information statement. 1. Residents #79, #124, #34, and #26 Review of the medical records for these residents on 06/28/17 at 2:00 p.m., revealed all four (4) medical records lacked documentation indicating the resident and/or the resident's legal representative received education regarding the current benefits and potential side effects of the influenza vaccine prior to administration during the current flu season. Resident #124 received the [MEDICATION NAME] flu vaccine on 10/11/16 and Residents #79, #34, and #26 received the [MEDICATION NAME] vaccine on 10/12/16. Licensed Practical Nurse (LPN) #119 reviewed the medical records during an interview on 06/28/17 at 2:40 p.m. and confirmed the records lacked any information related to consents and/or education regarding the benefits and potential side effects of the influenza vaccine. LPN #119 contacted Social Worker #143, the admissions person, and reported the only resident/family education provided was on the Pneumococcal & Annual Influenza Vaccination Information & Request form which was signed on admission and contained a revision date of 02/2007. During an interview at 3:00 p.m. on 06/28/17 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. The ADON reported the consent forms were not kept in the medical records. Resident #79's consent was not dated or signed. Resident #124's consent was signed on 10/05/16 with no identification of the person signing. Resident #34's consent was signed on 09/15/15 and Resident #26's consent was signed 09/18/15 with no identification of the family member signing. The ADON acknowledged there were no other consents or annual education provided to the resident and/or family prior to the yearly administration of the flu vaccine. The facility policy titled Immunizations - Pneumococcal & Annual Influenza stated under #3 of the guidelines on page 92: 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 states: Provide the resident and/or family with a copy of the applicable VIS (Vaccine Information Statement) .a. 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. The Centers for Disease Control and Prevention (CDC) updates its recommendations regarding the influenza vaccine annually based on information from the World Health Organzation (WHO) regarding the projected [MEDICAL CONDITION]. For example, For the (YEAR)-17 season, CDC recommends use of the flu shot (inactivated influenza vaccine or IIV) and the recombinant influenza vaccine (RIV). The nasal spray flu vaccine (live attenuated influenza vaccine or LAIV) should not be used during (YEAR)-17. The CDC also makes recommendations for certain populations such as the elderly, those who are immunocompromised, etc. The facility's influenza information was last updated in 2007. 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. and confirmed the Pneumococcal & Annual Influenza Vaccination Information & Request form with a revision date was 02/2007 could not contain the current information from CDC related to the benefits and potential side effects of the influenza vaccine. e) 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, the education sheets for the yearly flu vaccinations and immunization consents were incomplete for five (5) of five (5) sample residents reviewed for immunizations during the QIS survey. 1. 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. 2. 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. 3. 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 influen (TRUNCATED) | 2020-04-01 |