cms_WV: 6267
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6267 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 514 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the clinical health status/change of condition guideline, and staff interview, the facility failed to ensure the accuracy of the medical record for one (1) of three (3) residents reviewed for impaired skin integrity. The medical record did not reflect the status of an accident with injury. Resident identifier: #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on the wheelchair rim. The resident said the rim he used to propel himself had a sharp area on it. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff was to monitor the resident for skin tears and bruising for increased bleeding. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. No indication of skin impairment was evident. Further review of the medical record, on 01/22/14 at 1:01 p.m. revealed no order for treatment. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because it may have been related to the rust lifted. He added, I bled pretty bad. An interview with director of nursing (DON and executive director (ED), on 01/22/14 at 2:06 p.m.,revealed they were unaware of an injury or problem with the wheelchair. The DON said the policy was to complete a DQI (incident report) and the facility would follow up with the problem. The DON reviewed the progress notes and DQI reports and said no information was available. She also reviewed the medical record and confirmed it was incomplete. An interview with Employee #73 (LPN) on 01/22/14 at 2:07 p.m., revealed vital signs are obtained, the physician and family are notified, a DQI is completed, and an SBAR (change in condition note) is completed. She said staff was to monitor and continue charting for a certain number of days. The LPN said staff would note the response to care in the medical record. Review of the clinical health status/change of condition guideline, on 01/22/14 at 2:46 p.m., revealed the process for identification of change of condition included gathering of objective data and documenting assessment findings, resident response, physician and family notification. Communication, both written and verbal, and was to include a concise statement of the problem, pertinent and brief information related to the situation, subjective and objective assessment of condition, nurse's assessment of the situation, recommendation or action needed to correct the problem. An interview with the DON on 01/24/14 at 9:50 a.m., confirmed the clinical record was not maintained in accordance with accepted professional standards. The record did not provide an accurate picture of the resident's status, including assessment and treatment of [REDACTED]. | 2018-04-01 |