cms_WV: 6998
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6998 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 280 | E | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to update five (5) of forty-three (43) care plans reviewed during Stage 2 of the Quality Indicator Survey. Resident #38's care plan was not updated when the resident was placed on fluid restriction. Resident #39's care plan was not updated when the resident's contracture to her shoulder was resolved. Resident #91's care plan was not updated when padding was added to the side rails. Resident #25's care plan was not updated when side rails were changed from half side rails to quarter side rails. Resident #27's care plan was not updated to include the amount of assistance required to complete activities of daily living. Resident identifiers: #38, #39, #91, #25 and #27. Facility census: 130. Findings include: a) Resident #38 Review of the current care plan, which was revised on 09/16/13, found a problem identified as: Risk for dehydration related to diuretic use and fluid restriction related to [MEDICAL CONDITION]. An approach, initiated on 03/19/13, related to this problem was, keep fresh ice water at bedside. Review of the physician's orders [REDACTED]. The order specified how many cc of fluid the resident would receive with each meal and how many cc of fluid would be administered during each shift by nursing. Three (3) employees: a nursing assistant (Employee #132), a registered nurse (Employee #15), and a licensed practical nurse (Employee #140) were all interviewed at 2:46 p.m., on 12/09/13. All three (3) employees verified the resident could not have a water pitcher at his bedside. Employee #15 stated,It would be impossible to keep track of the amount of fluid consumed daily if the resident was allowed free access to a water pitcher. The author of the care plan, Employee #131, the registered nurse care plan coordinator, was interviewed at 3:30 p.m. on 12/09/13. She stated the resident's care plan should have been updated when the facility received the new order for fluid restriction. The new order was written on 09/12/13. The care plan was not updated when the order was written. In addition, the care plan was revised on 09/16/13; however, it was not updated at that time to reflect the new order written on 09/12/13. b) Resident #39 Review of the resident's current care plan, which was revised on 07/11/13, found a problem of, Risk for skin breakdown, pain, or further decrease in range of motion related to contractures of bilateral knees and hips and her left shoulder. The resident's most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/09/13 was reviewed. Section S-3100G was coded that the resident had contractures of both knees and hips. The prior MDS, with an ARD of 07/12/13, was coded that the resident had contractures of both knees, hips and left shoulder. Employee #131, the registered nurse MDS coordinator, was interviewed on 12/05/13 at 2:42 p.m. She stated, the contracture to the left shoulder had been resolved after the resident received therapy and this should have been removed from the care plan. c) Resident #91 At 2:00 p.m. on 12/10/13 Resident #91's bed was observed. The resident had bilateral 1/2 side rails which were covered with a lambs wool padding. The resident was asked how long the rails had been on her bed. She replied, As long as I can remember I use them to turn with. She stated the padding to the rails had also been on the rails for quite some time. The resident said it had not been on the rails the whole time, but it was added not long after she got the rails. Resident #91's medical record was reviewed at 2:11 p.m. on 12/10/13. The resident's medical record revealed a physician's orders [REDACTED]. The resident's initial care plan, which was originally initiated on 10/05/12, contained a care plan intervention for side rail covers to the side rails. This care was reviewed quarterly and continued to remain in effect until 09/18/13. On 09/05/13, the resident's care plan related to [MEDICAL CONDITION] disorder was updated. It did not contain the intervention for side rail covers/padding. The intervention of Lambs Wool covers to side rails for [MEDICAL CONDITION] precautions, was added to the resident's care plan on 12/06/13. There was no indication the resident's side rail covers were addressed on the care plan from 09/05/13 until 12/06/13. There was also no indication the resident's side rail covers were discontinued during that period of time. Employee #131, the MDS coordinator, was interviewed at 12:05 p.m. on 12/12/13. She stated if the order was still in effect, then the side rail covers/padding should have been on the residents care plan from 09/05/13 until 12/06/13. She confirmed the care plan did not contain this intervention during this time frame. An interview with Employee #86, Director of Nursing Services (DNS), was conducted at 11:46 a.m. on 12/12/13. She stated she could not locate any discontinued orders for the side rail padding for Resident #91. She confirmed the resident had padding to her side rails since 09/27/12. d) Resident #25 At 5:30 p.m. on 12/02/13, a tour of the facility was conducted to evaluate the usage of side rails. One side of this resident's bed was observed against the wall. The bed rail was up on the side of the bed that was not against the wall . This rail covered 1/2 (one-half) of that side of the bed. The rail was observed loose and could be easily shaken. At hat time, the facility was made aware of this situation. An observation on 12/03/13 verified this rail was no longer in use and there was a 1/4 (one-fourth) side rail present to only the top part of the bed. This was a smaller rail and did not cover the middle part of the mattress. The resident's care plan was reviewed on 12/05/13 at 1:00 p.m. This care plan identified the resident was at high risk for falls related to recent falls, poor muscle control, disregard of safety needs, non compliance with safety instructions / devices, incontinence, 9/19/13 repeated attempts to self transfer and 9/21/13 self transfers in and out of bed. The goal stated, Will not sustain serious injury through the review date. The interventions for this goal included placing the right side of bed against the wall to provide more floor space. Keep 1/2 (one-half) left side rail up and alarming floor mat to the left side of the bed. This was last revised on 06/12/13. There was no evidence the care plan was revised after the side rail was changed from a 1/2 (one-half) to a 1/4 (one-fourth) side rail on 12/02/13. The director of nursing (Employee #86) was interviewed on 12/03/13 at 2:00 p.m. She verified this resident's bed was changed on 12/02/13 when it was brought to the attention of the facility there was an issue with side rails. This resident got a new bed and new side rails. Employee #86 also verified the care plan was not revised when the side rails were changed, and still stated, remind him to use his 1/2 side rail. e) Resident #27 The MDS dated [DATE] for Resident #27 was reviewed on 12/11/13 at 11:00 a.m. The MDS assessment revealed Resident #27 was a two (2) plus person physical assist for bed mobility, transfers, and toileting. A review of Resident #27's care plan, dated 09/23/13, was conducted on 12/11/13 at 11:15 a.m. In the interventions for falls, the care plan indicated the resident was assessed as needing the assist of one (1) with toileting and transfers. The care plan was revised on 12/06/13 and the resident was still assessed as needing one assist for toileting and transfers. An interview with Employee #131 (MDS Nurse) on 12/11/13 at 11:30 a.m. revealed the current care plan was incorrect and should have stated Resident #27 was a two (2) person plus assist with toileting and transfers. | 2017-09-01 |