cms_WV: 7462
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7462 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 280 | E | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to revise the care plans, for four (4) of twenty-five (25) Stage 2 sample residents, to reflect changes in the residents' conditions. The care plans/interventions for maintenance of weight for Residents #204 and #116 were not revised after they experienced weight losses. Resident #122's care plan was not revised when deep tissue injury developed into a pressure ulcer. The nutritional care plan goals and interventions for Resident #157 were not revised when the resident began receiving hospice services. Resident identifiers: #204, #122, #116, and #157. Facility census: 113. Findings include: a) Resident #204 Medical records, reviewed on 06/12/13 at 9:30 a.m., disclosed a weight of 134.4# (pounds) on 04/23/13. On 05/14/13, the resident's weight was 126.4#. On 05/15/13, the dietitian noted the resident had experienced a weight loss of 7.8# in one month. This was a 5.8% (percent) weight loss in thirty (30) days, which was a significant weight loss. Further review revealed a recommendation by the dietitian for house shakes three (3) times a day between meals. Review of the resident's current care plan revealed a problem onset was noted on 03/14/13 stating, Nutritional status as evidenced by actual/potential weight loss to inadequate oral intake, mechanically altered diet, [MEDICAL CONDITIONS], constipation, depression, dysphasia, tobacco,[MEDICAL CONDITION] GERD. The care plan contained nothing regarding the resident's significant weight loss which was identified by the dietitian on 05/15/13. These findings were presented to Employee #28, a Registered Nurse (RN) and the Director of Direct Care (DCD) on 06/12/13 at 11:00 a.m. It was confirmed the care plan had not been revised to accurately reflect the weight loss and current needs of the resident. b) Resident #122 On 06/11/13 at 1:30 p.m., medical record review disclosed a suspected deep tissue injury (DTI) on the resident's right heel on 04/21/13. On 05/09/13, information on the medical record revealed the area had opened and was staged as a Stage 2 pressure ulcer. In addition, the medical record indicated a DTI on the left heel on 04/25/13. According to the record, it was healed as of 05/02/13. Review of resident's current care plan found a problem onset, noted on 04/21/13, stating Suspected DTI to right heel. There was no further evidence in the care plan of review or revision when the right heel opened and became a stageable pressure ulcer. The care plan for the left heel was a preventive care plan on 04/25/13. There was no evidence the care plan was reviewed or revised when the area was determined a DTI on 04/25/13 and/or when the area on the left heel was healed as of 05/02/13. These findings were reviewed with Employee #28, RN, DCD, on 06/11/13 at 3:30 p.m. At that time, Employee #28 confirmed the care plan had not been revised/updated concerning the areas on the resident's left and right heels. c) Resident #116 Review of the resident's electronic medical record found the resident's weight on admission on 01/07/13 the was 142 pounds. The most recent recorded weight was 126.4 pounds on 05/07/13. The most recent care plan which addressed nutritional status was created on 01/11/13. The problem noted was Nutritional status as evidenced by actual/potential weight loss/gain related to inadequate oral intake . The goal associated with this problem was: Will experience no significant weight change. The approaches to meet this goal, also created on 01/11/13, were: -Encourage and assist as needed to consume foods and or supplements and fluids offered; -Honor food preferences; -Provide diet as ordered; -Review weights and notify physician and responsible party of significant weight change; and -Snacks per patient preference. Medical record review revealed the dietary manager completed a nutrition/weight note on 02/06/13. The content of the note was: Significant wt. (weight) loss .Res. (resident) w/sig (with significant) wt loss after a sig (significant) gain the past month. Question wt. error for wt of 152.2# on 01/08/13 . At the time of the note the resident's weight was 138.8 pounds. The dietary manager, Employee #77, was interviewed on 06/10/13 at 3:30 p.m. She verified no new approaches were added to revise the care plan when the resident continued to experience weight loss. d) Resident #157 Medical record review found the resident was admitted to the facility on [DATE]. Review of a physician's telephone order, dated 04/26/13, found the resident began receiving Hospice services on 04/26/13 due to a [DIAGNOSES REDACTED]. This was included in the resident's current care plan. On 06/05/13, review of the resident's care plan revealed a problem addressing nutritional status: Nutritional status as evidenced by actual/potential weight loss/gain related to inadequate oral intake, mechanically altered diet with thickened liquids . The goal associated with this problem was: Will experience no significant weight change. An approach to this problem was: Review weights and notify physician and responsible party of significant weight change. Medical record review found an order to discontinue weighing the resident on 02/18/13. Employee #77, the dietary manager was interviewed on 06/05/13 at 9:50 a.m. She stated the care plan should have been revised, It was just an oversight and I will fix it right now. | 2017-04-01 |