cms_WV: 5587
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5587 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 323 | G | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide an environment that was free from accident hazards, over which the facility had control, for one (1) of four (4) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The resident had a history of [REDACTED]. Resident #25 had experienced an injury on 03/31/14. The facility had not ensured interventions were implemented to prevent additional falls from occurring. The facility also failed to lock a storage cabinet in the Unit 1 shower room. The cabinet contained items that were potentially hazardous when inhaled, ingested or came into contact with skin or eyes. This had the potential to affect more than a limited number of residents on Unit 1. Resident identifier: #25. Facility census: 154. Findings include: a) Resident #25 Review of the medical record, on 12/10/14 at 10:00 a.m., revealed the resident had an order, dated 10/20/14, to Transfer to hospital for evaluation and treatment related to fall. An incident detail, dated 12/20/14 at 2:00 p.m., was reviewed on 12/10/14. It noted the resident was in her geri- chair outside of her room and the resident was leaning over ar of chair reaching for the hand rail on the wall and she fell out of the chair and hit her head on the floor. The report also indicated staff observed a laceration above the right eye with bruising. The MDS with an assessment reference date (ARD) of 10/01/14, was reviewed on 12/10/14 at 11:00 a.m. The MDS revealed a brief interview for mental status (BIMS) score of 00, which indicated severe impairment. Section (G) noted transfers required extensive assist (non-weight bearing) of two (2). The MDS also noted the resident's balance was unsteady. Review of comprehensive care plan with a completed review date of 10/17/14, revealed the following : Focus, Resident is at risk for falls: impaired mobility, impaired cognition and incontinence and resident will continue to be able to use her wheelchair independently or with limited assist on the unit over the next 90 days. Goals, Resident will have no falls with injury for ninety (90) days and the resident will continue to be able to use her w/c independently or with limited assist on the unit over the next 90 days. Interventions, Dycem to wheelchair, low bed with landing strips, resident has a self release seatbelt for safety and is able to demonstrate on command removal of the seatbelt. Her daughter has requested this seatbelt. Staff to ensure the resident has this on while up and monitor for pressure.Review of the occupational therapy evaluation and progress notes, revealed Resident #25, received occupational therapy from 07/08/14 through 08/06/14 for a reported right lateral lean. No referral had been received for Resident #25 prior to her fall on 10/20/14. On discharge from therapy the recommendations were for the resident to be seated in a wheelchair with bilateral bolsters on arm rests and a knee separator. The resident was tolerating up to four (4) hours in with the positioning devices. During an interview with the director of nursing (DON) on 12/10/14 at 4:00 p.m.,confirmed the facility had not implemented the interventions to further reduce the risk for injury. b) Resident shower room on Unit 1 Observation of Unit 1's shower room with Registered Nurse (RN) #165 on 12/01/14 at 12:45 p.m., revealed an unlocked door into the shower room. Inside the shower room was a light tan in color plastic cabinet with an unlocked lock on the cabinet. Inside the cabinet were twenty- five (25) disposable razors, seven (7) bottles of shampoo and body wash, and three (3) cans of shaving cream. The RN agreed the items should have been locked up. She stated she would make sure the cabinet was locked. Review of the facility's material safety data sheets on 12/04/14 at 1:00 p.m., revealed they included hazard identification for shaving cream If any eye contact, flush with water, inhalation (prolonged) requires a person to be remove to fresh air, and ingestion is to induce vomiting. If the body wash can cause temporary moderate eye irritation. Ingestion may result in gastric disturbance. Review of the facility's policy on 12/04/14 at 1:05 p.m., revealed storage areas were to be locked when not in operation to prevent unauthorized access. | 2018-09-01 |