cms_WV: 7452
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7452 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2013-06-06 | 325 | D | 0 | 1 | L2MN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and staff interviews, the facility failed to provide appropriate care and services related for one resident's (#125) related to nutrition out of 3 residents who were reviewed for nutrition out of 7 residents with concerns related to significant weight loss since admission. Findings include: a) Resident # 125 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required set up only for eating and was not a physician's prescribed weight loss regimen. The medical record was reviewed and the resident's weights were as follows: The Admission Weights for this resident are: Weight at Admission (05/03/2013): 79 Weight at 15 days after Admission on (05/17/2013): 74 (which is 5 pounds less than at Admission or a 6.3% weight loss) Weight at 30 days after Admission on (06/01/2013): 75 (which is 4 pounds less than at Admission or a 5.1% weight loss). The Dietician assessed the resident on 5/8/13. The progress note indicated an initial assessment and the resident was on a regular diet, the resident's oral intakes were good, the resident weighed 79 pounds, a body mass index was 15.4 which indicated the resident was underweight and at risk for skin breakdown. On 5/23/13 the Dietician re-assessed the resident due to significant weight loss. The resident had an 8.7% weight loss in one week, a 6.3% weight loss in two weeks and the resident's current body weight was 74 pounds. The Dietician documented the resident's oral intake had declined with some meal refusals. The Dietician documented that per the staff the resident was taking fluids better than food and liked juice versus milk products. The Dietician recommended adding a supplement Ensure clear or [MEDICATION NAME] one box to all meal trays to increase calories and continue to monitor for changes. On 5/23/13 the [MEDICATION NAME]/Ensure clear one box to all meal trays was started and the percentage was recorded on the Medication Administration Record (MAR). Further review of the MAR's dated May 2013 and June 2013 was done. The nurses documented the supplement [MEDICATION NAME] one box with meals due to poor nutrition on 5/23/13 through 5/27/13. Starting on 5/28/13 through 6/4/13 the supplement was circled and documented by the nurses the supplement was not given because it was not available. A sticky note was posted on the MAR's for June that read: [MEDICATION NAME] will be in on Tuesday or Wednesday. The note was not signed or dated. On 6/4/13 at 2:25 P.M. Registered Nurse (RN) #183 was interviewed. The RN stated the resident received a new physician's orders [REDACTED]. The RN stated the [MEDICATION NAME] had not been given because it had been on back order and the dietary staff would bring it to the nursing unit when it arrived. MAR's circled from 5/28/13-6/4/13 documented the [MEDICATION NAME] was not available to give. At 3:00 P.M. the Dietary Manger #94 was interviewed. The Dietary Manager stated her staff brings the [MEDICATION NAME]/Ensure supplements to the units for the nurses to give. She was pretty sure there was [MEDICATION NAME] and Ensure in stock in the dietary department and was not aware the nursing unit was out of the product and did not know why nobody called to get it. She stated she would double check her inventory to see if they had the supplement in the dietary department. At 5:10 P.M. the Dietary Manager #94 stated she looked in the dietary department and there was no [MEDICATION NAME] or Ensure supplement. She stated she ordered the supplement today and it would be in on Thursday or Friday. She stated she looked back through her dietary orders and never received a slip from the nurses of the new order for the [MEDICATION NAME] supplement, so therefore it had never been ordered. She stated she was not aware the resident was supposed to receive the supplement. The Dietary Manager verified the resident did not receive the [MEDICATION NAME] supplement as ordered by the physician because there was not any in the facility to provide. On 6/5/13 at 12:50 P.M. the resident was observed to eat 70% of her meal. There was no [MEDICATION NAME]/Ensure clear on her tray. On 6/6/13 at 12:35 P.M. the resident was observed in the dining room eating lunch. There was no [MEDICATION NAME]/Ensure clear on her tray. A policy titled: Nutritional Supplement was provided by the facility. The policy indicated that residents who are ordered a nutritional supplement due to an increased need for calories and other nutrients shall be provided a product tailored to their individual needs. The policy indicated residents who are prescribed a nutritional supplement due to poor intake or weight loss, shall be prescribed by a physician. The dietician shall determine the most appropriate product and document the schedule, frequency and analysis of the supplement. The Food Service Department shall be responsible for providing the supplement to the nursing staff for passing to the resident. The nursing staff is responsible for passing the supplements and documenting the consumption on the MAR's. | 2017-04-01 |