cms_WV: 6250
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6250 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2014-02-21 | 225 | D | 0 | 1 | CYPG11 | Based on record review, staff interview, and review of the Center for Medicare and Medicaid Services (CMS) S&C-05-09 letter, the facility failed to investigate and report an injury of unknown source to appropriate agencies. One (1) of one (1) resident reviewed for accidents had a fractured finger. The facility had not investigated the injury or reported the injury to the appropriate outside agencies. Resident identifier #8. Facility census: 11. Findings Include: a) Resident #8 On 02/18/14 at 10:27 a.m., an interview with Employee #9, Registered Nurse (RN), revealed Resident #8 sustained a fracture to the left little finger within the past 30 days. Resident #8's medical record, reviewed at 8:46 a.m. on 2/19/14, revealed the following nursing notes: -- 02/08/14 at 5:40 p.m., .Combative with staff during ADL (activities of daily living) care and bed bath. Scratched one of the CNA's in her right eye and caused her contact lens to come out -- 02/09/14 at 10:48 p.m., (typed as written): .Resident complained of her lt (left) hand hurting. Staff then called me into room to assess. Assessment of lt hand revealed bruising on outside of hand from wrist down to pinkie. Bruising wrapped around to both top and under side of hand. Resident refuses cold packs on hand. resident can not verify how or when she hurt her hand. -- 02/10/14 at 11:31 a.m., (typed as written): (L) (Left) hand 4th and 5th fingers swollen and very bruised. pt. (patient) c/o (complains of) pain in (L) hand. X-ray of (L) hand ordered A review of the X-ray report revealed Resident #8 had a non-displaced fracture involving the proximal phalanx of the little finger. On 02/19/14 at 9:04 a.m., Employee #8,the RN Nursing Manager of the Long Term Care Unit, reported she usually handled the reportable incidents if it happens during the day. She said if it happened in off hours, the nursing manager on call handled the reporting of the incident. Employee #8 stated they had a meeting about Resident #8 and the fracture she sustained to her left hand. She reported they discussed the injury and assumed it happened when Resident #8 was resisting care. She said the resident likely hit the side rail with her hand. She stated they were not sure this was what happened, but this was their best guess. Employee #8 stated she did not speak with the nurse aides, nor did she do an in- depth investigation into what could have happened to Resident #8's hand. She stated she did not speak to the nurse aide, who also received a scratch to the eye on 02/09/14. Employee #8 stated she never thought about talking to her about it. She confirmed she also had not talked to any other staff members to see if they recalled Resident #8 hitting her hand on the side rail during care. Employee #8 stated she did not report this to OHFLAC and APS as an injury of unknown source. She agreed that, due to the extent of the injury, the fact no one observed the injury, and the resident could not recall what happened that it did constitute an injury of unknown source. She stated the facility should have reported this as required. Employee #8 further agreed she should have spoken with nurse aides whom had worked with Resident #8 and she should have completed an in-depth investigation in attempts to determine what happened to Resident #8's finger. Review of the CMS letter S&C-05-09 dated 12/16/04 revealed the following: An injury should be classified as an 'injury of unknown source' when BOTH of the following conditions are met: 1. The source of the injury was not observed by any person OR the source of the injury could not be explained by the resident; AND, 2. The injury is suspicious because of the extent of the injury OR the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) OR the number of injuries observed at one particular point in time OR the incidence of injuries over time. | 2018-04-01 |