cms_WV: 6078
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6078 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 154 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to fully inform residents who had been determined to possess the capacity to act as their own decision-maker, in a language that he or she could understand, of identified concerns regarding his or her total health status, including their cognitive status and psychosocial status as initiated in their individualized care plans. Residents were not informed of care plans established for behaviors. This was found for four (4) of four (4) residents who had voiced multiple documented complaints during 2013. Resident identifiers: #19, #62, #25, and #57. Facility census: 100. Findings include: a) Review of complaints, concerns, and abuse/neglect reporting began on 01/08/13 at 9:00 a.m. This review was continued and expanded on 01/20/14 as part of the extended survey protocol. 1) Resident #19 Review of the complaint/concern files identified this resident had thirty (30) documented concerns in 2013 to date. According to the documentation regarding these issues, the facility had attempted to resolve all of the resident's issues. The facility had not dismissed any of the resident ' s concerns as being unfounded or untrue. The high number of concerns filed by this resident prompted review of her medical record. This review the resident's physician had determined she possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score, as assessed on 12/17/13, was 15, indicating she was cognitively intact. She was acting as her own decision-maker. Review of her care plan, on 01/16/13 at 1:00 p.m., found she had a focus item for being at risk for changes in behavior problems related to making false accusations towards staff. The goal for this problem was (typed as written), Will remain free of behavioral disturbances daily thru next review. Interventions implemented toward meeting this goal were (typed as written): 1. Anticipate needs and provide care as able. 2. Provide emotional support as needed. Further review of the resident's medical record found there were no behaviors identified on the resident's minimum data set assessments. There was no evidence of any targeted behaviors being quantitatively monitored. There was no evidence of any behaviors, other than the frequency of her complaints. The record review found no basis for establishing the goal of (typed as written), Will remain free of behavioral disturbances daily thru next review. b) Following the review of Resident #19's medical record, patient liaison, Employee #176, was asked on 01/20/14 at 11:48 a.m., to provide a listing of residents who had voiced the most complaints and concerns in 2013. She provided the requested information a short time later, which indicated the following: 1) Resident #62 This resident had eleven (11) complaints/concerns/grievances documented. Resident #62 had been determined by a physician to possess the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 01/09/14 was 15, indicating she was cognitively intact. She was acting as her own decision-maker. She was currently president of the resident council. Review of her care plan, on 01/16/13 at 1:10 p.m., found she had a focus item for being at risk for behavior symptoms related to fabrications of staff refusing care/frequently making accusations toward staff and other residents. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Resident refuses psychiatric evaluation. 4. Use consistent approaches when giving care. 2) Resident #25 A review of the closed medical record for Resident #25 revealed she had been determined by a physician to possess the capacity to make informed medical decisions. This was verified in each of her care plan meeting minutes 07/24/13,08/08/13, and 10/16/13). She had scored 15/15 on the BIMS (Brief Interview for Mental Status) on 10/18/13. She was her own decision-maker during her stay at the facility. A review of the Concern Report files revealed Resident #25 had nine (9) grievances documented during her admission at the facility from 07/23/13 to 11/08/13. Review of the complaints and concerns found that the facility had attempted to resolve all of the issues. None had been dismissed as being unfounded or untrue. A review of her care plan, at 1:37 p.m. on 01/16/13, found she had a focus item for being noted to make false accusations towards staff related to [MEDICAL CONDITIONS]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Use consistent approaches when giving care. Medical record review found that although she had a care plan focus item related to being at risk for behaviors due to making false allegations or fabrications, there was no evidence of behaviors documented on the resident ' s comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. The only progress note in the entire record alluding to behaviors was the following on 10/18/13, which was the initiation date of the care plan for this focus, (typed as written) Nurse was standing outside of room passing medications when resident call light came on. Nurse finished passing pills that were already started. Nurse answered call light. Resident states, ' Its about time my call light has been on for an hour. ' Nurse explained to resident that she was standing outside of the room when the call light came on but I would be glad to assist her in repositioning. Resident states, ' You are just like everyone else, liars. ' Will continue to monitor. There was no entry in any of the physician's progress notes suggesting the presence of any behaviors. An interview was conducted with acting social services director, contracted Employee #44 on 1/21/14 at 11:50 a.m. She was identified by the Administrator, Employee #120 as the person responsible for facilitating resident care plan meetings. She was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. There was no evidence of behaviors being discussed in any of her care plan meeting minutes (07/24/13, 08/08/13, and 10/16/13) and her daughter had been in attendance at two (2) of the meetings. 3) Resident #57 This resident had eight (8) complaints/concerns/grievances documented. Resident #57 had experienced a recent significant change of condition and was determined by her physician to lack the capacity to make informed medical decisions on 12/27/13 due to illness/early dementia. Prior to that determination, she had acted as her own responsible party throughout her residency in 2013. Her Brief Interview for Mental Status (BIMS) score, as assessed on 11/27/13 was 15, indicating she was cognitively intact. Review of her care plan on 01/16/13 at 1:42 p.m. found she had a focus item for being at risk for behavior symptoms such as making false accusations towards staff and family related to mental illness and [MEDICAL CONDITION]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer meds per physician orders, observe for effectiveness and side effects such as but not limited to dizziness, drowsiness, and falls. 2. If resident exhibits inappropriate behaviors, speak in a soft, calm tone, attempt to redirect, and encourage resident to express herself in a more appropriate manner. 3. Observe for mental status/behavior changes when new medication started or with changes in dosage. 4. Use consistent approaches when giving care. c) Review found each of these residents had care plan focus items related to being at risk for behaviors due to making false allegations or fabrications, although none of them had evidence of behaviors documented on their comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. d) In an interview with the acting social services director, contracted Employee #44, on 01/21/14 at 11:50 a.m. (she was identified by administrator, Employee #120, as the person responsible for facilitating resident care plan meetings), she was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. It was then discussed that review had found those residents having the most complaints all had care plan focus items bringing their credibility into question. She was asked if the focus item related to making false allegations or fabrications had been discussed with these residents. She said they had not. | 2018-05-01 |