cms_WV: 4087

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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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
4087	DUNBAR CENTER	515066	501 CALDWELL LANE	DUNBAR	WV	25064	2016-07-19	309	E	0	1	KKFY11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, resident interview, and staff interview, the facility failed to ensure physician ordered restrictions for no blood pressures to be taken in Resident #109's left arm six (6) of fifty-nine (59) times. The facility did not ensure Resident #109's condition was assessed prior to going to [MEDICAL TREATMENT] treatment and failed to ensure coordination of care with the [MEDICAL TREATMENT] center on eleven (11) of sixteen (16) days reviewed. Additionally, there was no evidence the facility assessed Resident #109 and identified that the resident experienced two (2) falls that were within one (1) hour of her returning from [MEDICAL TREATMENT]. This affected one (1) of one (1) resident reviewed for the care area of [MEDICAL TREATMENT] during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #109. Facility Census: 105. Findings include: a) Resident #109 1. Medical record for Resident #109 beginning on 07/12/16 at 2:00 p.m., revealed a physician's orders [REDACTED]. Review of the Vital Sign Summary sheet on 07/12/16 at 2:00 p.m., revealed Resident #109 had her blood pressure checked in her left arm at least six (6) times since 03/11/16. The vital sign summary record did not always specify in which arm her blood pressure was taken, but on 04/03/16, 05/06/16, 05/08/16, 05/22/16, 05/23/16, and 06/28/16 it was identified the left arm was used. 2. Further review of the medical record on 07/12/16 at 2:00 p.m. found the resident's scheduled days for [MEDICAL TREATMENT] were Monday, Wednesday, and Friday. Review of the communication record shared between the facility and the [MEDICAL TREATMENT] center found the facility was to complete the top half of the form, which included the resident's vital signs, weights prior to [MEDICAL TREATMENT], an examination of the access site, the time of the resident's last meal, medications given prior to [MEDICAL TREATMENT], resident's general condition, and any special instructions. The bottom half of the communication form, to be completed by the [MEDICAL TREATMENT] center included weights after [MEDICAL TREATMENT], vital signs, laboratory work done, medications given, intake and output, monitoring of the access site, any change in condition, and any other pertinent information that would need communicated. Eleven (11) of sixteen (16) [MEDICAL TREATMENT] communication records reviewed were incomplete. The communication records were incomplete on 05/13/16, 05/20/16, 06/06/16, 06/15/16, 06/17/16, 06/20/16, 06/22/16, 06/26/16, 06/29/16, 07/06/16, and 07/11/16. Licensed Practical Nurse (LPN) #149, verified on 07/18/16 at 10:20 a.m. the [MEDICAL TREATMENT] communication records were not complete. The LPN stated they were to assess the resident and complete the top section before she left for [MEDICAL TREATMENT] and then the [MEDICAL TREATMENT] center was to complete the bottom section and send it back after the resident received treatment. LPN #149 stated the [MEDICAL TREATMENT] center sent the form back blank at times and someone should call them and obtain the information. The LPN verified there was no evidence anyone obtained this information on the 11 identified days. On 07/13/16 at 2:00 p.m., the Director of Nursing (DON) was made aware the [MEDICAL TREATMENT] communication sheets were incomplete. On 07/19/16 at 9:30 a.m., the DON provided a policy for the [MEDICAL TREATMENT] communication. The facility Policy titled NSG 253 [MEDICAL TREATMENT] Communication and Documentation with an effective date of 05/01/16, reviewed on 07/19/20 at 10:15 a.m. included the following: - Policy: Center will Communicate with the [MEDICAL TREATMENT] center prior to sending a patient for [MEDICAL TREATMENT] by completing the [MEDICAL TREATMENT] Communication Record and sending it with the patient. This form will also be completed upon return of the patient from the [MEDICAL TREATMENT] center. Purpose: To obtain highest continuum of care for patients receiving [MEDICAL TREATMENT] services. Practice Standards: -- Prior to a patient leaving the Center for outpatient [MEDICAL TREATMENT], a licensed nurse will complete the top portion of the [MEDICAL TREATMENT] Communication Record and send it with the patient to out patient [MEDICAL TREATMENT] center. -- Following completion of the out-patient [MEDICAL TREATMENT] treatment, the [MEDICAL TREATMENT] nurse should complete the form and return it or other communication to the Center with the patient. -- Upon return of the patient to the center, the licensed nurse will review the [MEDICAL TREATMENT] center communication; evaluate/observe the patient; and document the evaluation /observation on the [MEDICAL TREATMENT] communication record. -- Notify the [MEDICAL TREATMENT] center if the form is not returned with the patient and ask it be faxed to the center. -- Document notification of [MEDICAL TREATMENT] center regarding return of form or other communication. 3. At 4:00 p.m. on 07/12/16, a review of the falls incident reports experienced by Resident #109, identified the falls on 05/14/16 and 06/29/16 occurred within one (1) hour of the resident's return to the facility following her [MEDICAL TREATMENT] treatments. During an interview on 07/13/16 at 8:35 a.m., when asked about her previous falls, she stated when she returned from [MEDICAL TREATMENT], she was so weak she could not stand up. She stated her call light was often on the floor and she could not reach it and she had to go to the bathroom she tried to get up and that was when she fell because her legs just gave out. Review of Resident #109's active care plan revealed the facility failed to identify the resident's increase risk for falls and increased weakness after she returned from [MEDICAL TREATMENT] treatments. Nurse Aide (NA) #93 verified on 07/13/16 at 8:45 a.m. that NAs did not have access to the care plans, but got the information they need to care for a resident on the Kardex in the Activity of Daily Living book. Review of the Kardex 07/13/16 at 9:00 a.m. revealed there was no information provided to the caregivers regarding the increased need for supervision upon returning from [MEDICAL TREATMENT]. During an interview with the Director of Nursing (DON) on 07/13/16 at 2:00 p.m., she was made aware that the facility did not revise the care plan to identify Resident #109 was at an increased risk for falls upon returning from [MEDICAL TREATMENT] and verified the care plan had not been revised to include this issue.	2020-02-01