cms_WV: 6271

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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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
6271 HILLTOP CENTER 515061 152 SADDLESHOP ROAD HILLTOP WV 25855 2015-04-16 315 D 1 0 AU7811 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to ensure one (1) of ten (10) residents reviewed received treatment and services to maintain or restore as much bladder function as possible. The facility failed to fully implement a planned voiding diary to assess the resident's bladder continence/incontinence; therefore, appropriate interventions were not planned and implemented to maintain or restore as much bladder function as possible. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the electronic medical record (EMR), on 04/14/15 at 2:49 p.m., revealed Resident #114 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Her brief interview for mental status (BIMS) score was 14, which indicated minimal cognitive impairment. A score of 15 is the highest available score. The minimum data set (MDS), with an assessment reference date (ARD) of 01/30/15, reviewed on 04/14/15 at 2:51 p.m., revealed urinary incontinence triggered under section V, with a decision to care plan the problem. The care plan, reviewed on 04/14/15 at 3:17 p.m., indicated Resident #114 required extensive/ total assist with activities of daily living (ADL) care, which included toileting. The care plan indicated the resident was cognitively impaired and unable to participate in a toileting program, even though the BIMS score was 14. Urinary incontinence nursing interventions, dated 02/13/15, noted functional incontinence with use of absorbent products. A nursing assessment, dated 01/30/15, indicated Resident #114 believed she was able to improve in some areas of activities of daily living (ADLs.) Another nursing assessment, dated 02/18/15, noted the resident was frequently incontinent of bowel - not on a toileting program and frequently incontinent of urine - not on a toileting program. A third nursing assessment, dated 03/17/15, indicated Resident #114 was always incontinent of bowel with no toileting program and occasionally incontinent of urine with no toileting program. Review of the continence management policy, on 04/16/15 at 9:00 a.m., revealed a three (3) day voiding diary would be completed, and a plan of care developed, based on information from assessments and the diary. The three (3) day voiding diary, completed 01/29/15 through 01/31/15, was reviewed on 04/14/15 at 3:45 p.m. It had not been completed every two (2) hours as required: -- On 01/29/15, there were no entries for 7-9 p.m., 9-11 p.m., 11 p.m.-1 a.m., 1-3 a.m., 3-5 a.m. and 5-7 a.m. -- On 01/30/15, there were no entries for 11 a.m.-1 p.m., 1-3 p.m., 3-5 p.m., 5-7 p.m., 7-9 p.m., 9-11 p.m., 11 p.m.-1 a.m., 1-3 a.m., 3-5 a.m., and 5-7 a.m. -- On 01/31/15, there were no entries for 3-5 p.m., 5-7 p.m., 7-9 p.m., 9-11 p.m., 11 p.m.-1 a.m., 1-3 a.m., 3-5 a.m., and 5-7 a.m. Additionally, only one (1) of twelve (12) entries indicated the resident was toileted. Five (5) of five (5) entries indicated the resident was dry, but not toileted to promote continence. A care plan intervention, dated 03/05/15, indicated a three (3) day voiding diary would be completed to evaluate for patterns of incontinence at appropriate intervals. Review of the medical record provided no evidence of this assessment. The care plan indicated a prompted toileting program was not initiated until 03/17/15, although the resident was identified as requiring assistance on 03/05/15. Review of the activity of daily living (ADL) sheets revealed Resident #114 was incontinent for fifty eight (58) of fifty nine (59) entries in February 2015. The March 2015 ADL sheets indicated the resident was incontinent 03/01/15-03/09/15 on night shift and on 03/01/15-03/05/15. During an interview with the director of nursing, on 04/15/15 at 10:00 a.m., she confirmed the voiding diary was not implemented as required by their policy. She also acknowledged the facility had not assessed and provided appropriate treatment and services to maintain as much normal urinary function as possible and/or to improve the resident's urinary functioning. 2018-04-01