cms_WV: 4090
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4090 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 323 | D | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to ensure Resident #109 received adequate supervision and assistive devices to prevent accidents. Resident # 109 could not reach her walker and her call light was in the floor and out of her reach.There was no clip or method to secure the call light so it could not fall in the floor. The facility also failed to ensure an assessment was completed and supervision was provided upon the residents return from dialysis after two (2) falls were experienced within one (1) hour of her returning from dialysis treatment. This was true for one (1) of five (5) residents reviewed for the care area of Accidents in Stage 2 of the QIS survey. Resident identifier: # 109. Facility Census: 105. Findings include: a) During an observation 07/12/16 at 9:00 a.m. Resident #109's environment was observed. The resident was observed sleeping in bed, her walker was observed folded up behind the curtain out of her reach. Review of Resident # 109's Medical Record on 07/13/16 at 8:00 a.m., revealed this resident had a history of [REDACTED]. Interventions established to meet this goal included Non-slip socks when out of bed without shoes, one person assist with transfers, place walker within reach, remind resident to use call light when attempting to ambulate or transfers. Dialysis Communication forms were observed to be incomplete and there was no evidence the resident was assessed upon her return from Dialysis treatments. Resident #109 was observed again on 07/13/16 at 8:20 a.m., sitting on the side of her bed eating breakfast. Her walker was again observed behind the curtain folded up and not within her reach. Her call light was observed laying in the floor. Resident #109 had on a pair of regular socks that were not non-skid and her empty wheelchair was sitting in the hall. During an interview with Resident #109 on 07/13/26 at 8:35 a.m., the resident stated her call light is often in the floor and she can not reach it and she has to go to the bathroom so she tries to get up and that is when she falls because her legs give out. She stated there is no way to hook her light cord so it doesn't fall in the floor. Resident #109 stated when she returns from Dialysis she is so weak she can not stand up. Interview with Employee #93, Nursing Assistant (NA), 07/13/16 at 8:45 a.m., verified he was taking care of Resident #109. This NA was questioned about the walker for Resident #109 and stated this resident has not used her walker for a while. He was made aware of the call light on the floor and made aware there was no way to clip this call light on the bed to prevent it from falling out of the resident's reach. Employee #93 verified the call light could not be secured on the bed and placed a clip on her call light so he could attach it to the sheets to prevent it from falling in the floor. 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 that Resident #109 was an increased risk for falls upon returning from dialysis and did not implement measures that had been initiated to prevent falls from re-occurring. There was no evidence the facility reassessed this resident or identified she needed increased supervision after she returned from dialysis. | 2020-02-01 |