cms_WV: 5981
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5981 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 314 | G | 0 | 1 | GZSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on minimum data set (MDS) review, medical record review, observation, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for pressure ulcers during Stage 2 of the survey did not develop an avoidable pressure ulcer. The facility failed to implement interventions in an effort to prevent the development of the pressure ulcer. An in-house acquired suspected deep tissue injury (DTI) was identified on the resident's heel seven (7) days after readmission to the facility. The facility was unable to provide evidence of the implementation of interventions to prevent the development of the pressure ulcer or to assist in the healing of the pressure ulcer once it was identified. Resident identifier: #65. Facility census: 59. Findings include: a) Resident #65 On 10/08/14 at 9:30 a.m., a review of the medical record revealed the resident was readmitted from a local acute care hospital on [DATE]. The medical [DIAGNOSES REDACTED]. At 11:04 a.m. on 10/09/14, a review of the resident's significant change MDS, with an assessment reference date (ARD) of 08/25/14, revealed Section M, G-2 was coded that a suspected DTI was present on readmission to the facility on [DATE]. Section M1200 B and C also noted a pressure reducing device and a turning/repositioning program was in place. This information was carried forward on the MDS's with ARD's of 09/23/14 and 10/01/14. Additional medical record review revealed Resident #65 was not readmitted with a suspected DTI. According to the medical record, on 08/07/14 an in-house acquired suspected DTI to the left heel was identified. Observation, on 10/14/14 at 8:15 a.m., revealed no pressure reducing device was on the bed of Resident #65. The care plan contained two (2) problem statements related to pressure ulcers: -- On 08/12/14, the care plan indicated the resident had a Stage II pressure ulcer on the coccyx related to decreased mobility, related to a fractured pelvis. The care plan did not contain any interventions relative to care of the resident while she was in bed to prevent further skin breakdown and/or to promote healing of the pressure ulcer. -- On 09/12/14, the care plan noted the resident had a suspected deep tissue injury (DTI) on the left heel related to the fractured pelvis. The care plan failed to have interventions related to care to prevent further skin breakdown, to promote healing of the area, or for the use of a pressure relieving boot device which was ordered by the physician. Neither care plan problem statements contained anything relative to a turning/repositioning program, as the MDS indicated was in place. An interview with the director of nursing (DON), on 10/14/14 at 10:34 a.m., confirmed the suspected DTI was not present on readmission and had developed in the facility. In addition, the DON confirmed no pressure relieving device had ever been used on Resident #65's bed. Upon inquiry, the DON was also unable to provide evidence the resident was on a turning/repositioning program. | 2018-05-01 |