cms_WV: 5991
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5991 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 226 | F | 0 | 1 | 7HHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's abuse/neglect assessment and reporting policy, review of the complaint files, staff interview, and personnel file review, the facility failed to operationalize its policies related to allegations of neglect and abuse for three (3) of seven (7) residents. The allegations were not reported and investigated as required by their policy titled: Abuse, Neglect, Reporting Forms. In addition, the facility failed to operationalize its policies and procedures for screening employees for protection of residents from abuse, neglect, mistreatment, and misappropriation of property. The facility also failed to operationalize its policy to be thorough in the investigations of the past histories of five (5) of five (5) employees they hired. These practices affected Resident #52, #148, and #156. The practices had the potential to affect all residents. Facility census: 98. Findings include: a) Resident #52 Review of a grievance/concern form, at 4:00 p.m. on 09/17/14, revealed the resident reported allegations of neglect and verbal abuse on 07/14/14, regarding incidents which occurred on 07/12/14 and 07/13/14: 1. Resident reports Licensed Practical Nurse #19 is very rude and hateful, and she is untimely with medications and she thinks she gave her two [MEDICATION NAME] instead of her pain medication. 2. Staff didn't provide a bed pan in timely manner. A notation on the form, under findings of the investigation, revealed the facility found the employee was perceived by the resident as rude and hateful. The corrective action was: Instructed to be mindful of how she is being perceived by resident when giving care. There was no evidence of a thorough investigation into the complaints. There was nothing which indicated how the facility determined the resident's complaint was only a perception that the employee was rude or hateful. There was no evidence of an thorough investigation regarding the resident's medication concerns or the timely provision of a bedpan. In addition, these allegations of verbal abuse and neglect were not reported to the required state agencies. During an interview with the Administrator, at 4:30 a.m. on 09/17/14 , the administrator was asked why the allegations were not reported as allegations of neglect and verbal abuse. She stated she had not considered the concern to be a reportable. The administrator agreed the facility did not implement their policy to investigate thoroughly and to report to the required state agencies. b) Resident #148 A review of a grievance/concern form, at 4:05 a.m. on 09/17/14, revealed several allegations made by the resident's daughter, on 08/11/14, regarding incidents which occurred on 08/09/14 and 08/10/14: 1. Resident #148's daughter stated She was upset to find her mother in her bed with the head of bed way down and her mother's butt was up in the air. (She said blood was rushing to her head)? Sat nite she said that her pants were down below her butt and side rails were down. The daughter said that she did not understand why they would have her in that position in her bed. 2. Daughter stated that her mother told her They are mean to me. Daughter said that when she asked her mother what they were doing mean to her she just shut up. 3. The daughter stated a friend had come to visit with her mother and her mother told her friend They are mean to me. The friend stated while visiting with her mother on Sunday night (08/10/14), she heard a nurse speak grouchy to a resident that was requesting eye drops. The daughter is concerned that since she has reported the incident that people will be mean to her mother now. The administrator assured the daughter that would not be tolerated by administration. A notation on the form, under findings of the investigation, indicated the facility checked the resident frequently, staff had found the resident positioned properly, she appeared to be in no distress, and was resting comfortably. There was no date or time the check occurred. The corrective action was: Educated all staff regarding positioning and communication skills. Will continue to maintain communication with family and address concerns whenever. The facility did not investigate the complaint regarding the resident stating, They are mean to me. There was no evidence of a thorough investigation regarding these allegations of verbal abuse and neglect. In addition, these allegations were not reported to the required state agencies. During an interview with the Administrator, at 4:45 p.m. on 09/17/14, she was asked why the allegation was not reported as allegations of neglect and verbal abuse. She stated she thought it was only a concern and did not consider the concern to be reportable. The administrator agreed the facility did not implement their policy to investigate thoroughly and to report to the required state agencies. c) Resident #146 A review of a grievance/concern form, at 4:10 p.m. on 09/17/14, revealed the resident voiced an allegation of neglect on 07/03/14, for an incident on 07/02/14: 1. The resident stated she asked for a whenever needed (PRN) pain pill. Allegedly she was told it was change of shift, and then it Took over three hours for the nurse to bring it. The resident's alert and oriented roommate confirmed the verbal report. A notation on the form, under findings of the investigation, revealed [MEDICATION NAME] was administered at 2210. The form indicated the licensed practical nurse (LPN) #19 denied the resident's request; however the resident and her roommate both verified the resident asked for pain medication around 7:00 p.m. (shift change). Nursing assistant (NA) #64 reported telling the charge nurse (CN) #30 and licensed practical nurse (LPN) #19 around 9:00 p.m. that Resident #146 had told the NA that she had been waiting two (2) hours for a pain pill. The NA stated the LPN was doing her routine medication pass on the hall and the LPN told NA #64, I'll be there when I can. NA #64 stated the LPN Waited until she got to Hall 4. According to the form, LPN #19 received education regarding responding to residents' requests for pain management; however, there was no evidence a thorough investigation was completed. In addition, these allegations of neglect were not reported to the required state agencies. During an interview with the Administrator at 5:00 p.m. on 09/17/14 , the administrator was asked why the allegation was not reported as an allegation of neglect. She stated she had not considered the concern to be reportable. The administrator agreed the facility did not implement their policy to investigate thoroughly and to report to the required state agencies. d) In an Interview with the social worker (SW) #93, on 09/18/14 at 11:46 a.m., she was asked to review the grievance/concern forms for Residents #52, #148 and #146. When asked if these grievance/concern forms contained allegations of neglect and verbal abuse, she replied yes. When the SW was asked if the allegations regarding Residents #52, #148, and #146 were thoroughly investigated and reported to the required state agencies, she stated No. When asked if the facility implemented their Abuse/Neglect policy regarding these residents allegations, the SW responded, No. e) A review of the facility's abuse /neglect assessment and reporting policy, on 09/17/14 at 1:53 p.m., revealed directives for investigation and reporting of all abuse and neglect allegations, and The facility will utilize the Abuse/Neglect Reporting Requirement for WV Nursing Homes and Nursing Facilities to determine reporting requirements. f) Abuse Registry Checks Employees #15, #22, #63, and #73: A review of personnel files found the facility had not completed thorough abuse registry checks for Employees #15, #22, #63 and #73. These employee was involved in direct resident care. An Interview was conducted with the assistant director of nursing, at 3:00 p.m. on 09/17/14. She stated after searching the employees' files, there was no record the abuse registry was checked for Employees #15, #22, #63, and #73. g) State Wide and National Criminal Background Checks The Patient Protection and Affordable Care Act (Pub. L. 111 - 148, enacted March 23, 2010) and the Health Care Education Reconciliation Act of 2010 (Pub. L. 111 - 152, enacted March 30, 2010), together are known as the ACA. The legislation authorized long term care (LTC) facilities and providers to obtain State and national fingerprint based background checks from potential employees whose duties include direct access to residents and patients. To ensure the facility has not employed an Individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of Law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. The Bureau for Medical Services manual Includes: 514.4.1 Employment Restrictions Criminal Investigation Background: Check (CIB) Results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based state level criminal investigation background check must be conducted, initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check using fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities, 02/15/13. The memo included, At a minimum, a fingerprint-based state level criminal investigation background check must be conducted, initially by the employer, prior to hire and every three (3) years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility, until 03/01/14, to have all current employees up-to-date with criminal investigation background checks . For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013. Employee #15, #22, #63, #65 and #73: 1. Licensed practical nurse (LPN) #15's personnel file was reviewed at 1:00 p.m. on 09/17/14. LPN #15 was hired on 08/25/14. The personnel file did not contain any evidence of fingerprinting as required for a West Virginia criminal background check. 2. LPN #22's personnel file was reviewed at 1:05 p.m. on 09/17/14. LPN #22 was hired on 05/05/14. The personnel file did not contain any evidence of fingerprinting as required for a West Virginia criminal background check. 3. Nursing assistant (NA) #63's, personnel file was reviewed at 1:08 p.m. on 09/17/14. Nurse Aide #63 was hired on 08/25/14. The personnel file did not contain any evidence of fingerprinting as required for a West Virginia criminal background check. 4. NA #65's personnel file was reviewed at 1:10 p.m. on 09/17/14. NA #65 was hired on 09/08/14. The personnel file did not contain any evidence of fingerprinting as required for a West Virginia criminal background check. 5. NA #73's personnel file was reviewed at 1:10 p.m. on 09/17/14. Nurse Aide #73 was hired on 08/11/14. The personnel file did not contain any evidence of fingerprints being taken as required for a West Virginia criminal background check. An Interview was conducted with the assistant director of nursing, at 3:05 p.m. on 09/17/14. She stated after searching the employees' files, there was no record of a West Virginia (WV) state wide criminal background check on these employees. | 2018-05-01 |