cms_WV: 5918
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5918 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2014-10-15 | 281 | D | 0 | 1 | 8R4I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the instructions for administering Fleets enemas, the facility failed to ensure services provided to residents met professional standards of quality. A nurse administered a Fleets enema to a resident while the resident was standing. One (1) of twenty-nine (29) residents reviewed in Stage 2 of the Quality Indicate Survey was affected. Resident identifier: #59. The Stage 2 sample size was 29. Facility census: 142. Findings include: a) Resident #59 Review of the resident's clinical record revealed this [AGE] year-old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS), a significant change in status assessment, dated 09/10/14, documented Resident #59 was cognitively intact and required the extensive physical assistance of two (2) staff for transfers and toileting. Review of the care plan, dated 09/02/14, for Resident #59 documented she required the physical assistance of two (2) staff for transfers and the staff were to use a gait belt during transfers. Resident #59's functional status care plan was updated on 10/10/14 after she fell in the bathroom when only one (1) staff member was assisting her. The updated care plan indicated Resident #59 was unable to perform activities of daily living independently related to weakness, arthritis, balance during transfer, and walking. She was noted to be unsteady when moving from a seated to standing position and was not steady with any surface to surface transfers. The care plan also documented Resident #59 required two (2) staff to assist her with transfers and the staff were to use belt around her waist during transfers. Review of the nurses' notes dated 10/06/14 at 4:26 p.m., revealed Resident #59 was in the hall bathroom with one (1) staff, Licensed Practical Nurse (LPN) #37, and was standing at the toilet holding onto the safety bar while the nurse was administering a Fleets enema. The resident was noted to start to sit down unexpectedly before a shower chair could be placed under her. Review of the incident report revealed the LPN #37 was alone with Resident #59 while administering an enema to her when the resident fell . An interview was conducted on 10/15/14 at 9:25 a.m. with LPN #37 who was the nurse that was with Resident #59 at the time of the fall. She stated to be honest she was not aware of the resident's transfer status at the time of the fall. She verified she was alone with the resident when the resident fell in the bathroom. This information was shared with the Director of Clinical Operations #94 and the Director of Nursing Staff #60 on 10/15/14 at 10:00 a.m. Review of the instructions for administering a Fleets found they included: Place patient in a left side-lying position with knees flexed. To facilitate flow of solution using contour of the bowel. Place bedpan next to patient. For easy access in case patient cannot hold enema solution. Positions for using this enema: -- Left-side position: Lie on left side with knee bent, and arms resting comfortably. -- Knee-chest position: Kneel, then lower head and chest forward until left side of face is resting on surface with left arm folded comfortably. Proper and safe use of FLEET(R) Enemas also requires that the products be administered according to the Directions. Healthcare professionals should remember when administering the product to gently insert the enema into the rectum with the tip pointing toward the navel. Insertion may be made easier by having the patient bear down as if having a bowel movement. Care during insertion is necessary due to lack of sensory innervation of the rectum and due to possibility of bowel perforation. | 2018-05-01 |