cms_WV: 7761
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7761 | CLAY HEALTH CARE CENTER | 515142 | 1053 CLINIC DRIVE | IVYDALE | WV | 25113 | 2013-04-16 | 514 | B | 0 | 1 | KUG911 | Based on medical record review and staff interview, the facility failed to maintain an accurate, complete and systemically organized medical record for nine (9) of thirty-four (34) medical records reviewed during Stage 2 of the survey. The medical record of each resident contained forms which were not fully completed with dates and/or signatures. Records were requested for Resident #12, and the facility was unable to locate the records. In addition, information regarding the consultant pharmacist's monthly medication regimen review was not in each resident's medical record. Resident Identifiers: #12, #34, #50, #63, #57, #2, #30, #27, and #64. Facility census: 57. Findings Include: a) Resident #12 At 3:30 p.m. on 04/03/13, the resident's restorative documentation for the months of January 2013 through March 2013 was requested from the director of nursing (DON). At 11:30 a.m. on 04/04/13, the DON reported they could not locate the requested restorative records. She reported they would continue to look for them. At the time of exit, at 4:30 p.m. on 04/16/13, the facility was unable to provide the requested records for Resident #12. b) Resident #34 A medical record review was conducted at 12:54 p.m. on 04/15/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of February 2013 and March 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on either form. c) Resident #50 A medical record review was completed at 10:00 a.m. on 04/11/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of January 2013, February 2013, March 2013 and April 2013. These form contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms. d) Resident #63 A medical record review was completed at 11:30 a.m. on 04/11/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of January 2013, February 2013, March 2013 and April 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms. e) Resident #57 A medical record review was completed at 11:15 a.m. on 04/15/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of February 2013, and March 2013. This form contains a box which was labeled nurses signature (in accordance with state law). This box was not signed nor dated on the forms. f) Resident #2 A medical record review was completed at 2:00 p.m. on 04/15/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of January 2013, February 2013, and March 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms, with the exception of the February form which was dated, but not signed. g) Resident #30 A medical record review was completed at 10:00 a.m. on 04/10/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of January 2013, February 2013, March 2013 and April 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms. h) Resident #27 A medical record review was completed at 10:00 a.m. on 04/11/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of February 2013, March 2013 and April 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms. i) Resident #64 Medical record review, on 04/11/13 at 9:45 a.m., revealed the resident was admitted to restorative nursing services on 01/23/13 for ambulation and transfers. Further review of the medical record on 04/15/13 revealed the resident's restorative care plan was not signed by a nurse for the months of February 2013, March 2013, and April 2013. The restorative nursing participation logs for the months of January 2013, February 2013, March 2013, and April 2013 were reviewed. The months of February 2013, March 2013, and April 2013 were all incomplete, as nursing staff failed to provide an explanation for why services were not provided on the days the resident had no participation recorded. An interview with the nursing home administrator (NHA), at 2:34 p.m. on 04/15/13, confirmed the forms were not signed or dated by the nurse. j) Residents #64, #53, #12, #23, #36, #38, #9, #14 Review of these residents' medical records, which contained the registered pharmacist consultant reviews, revealed the consultant pharmacist did not indicate if there were or were not irregularities. The facility's policy regarding documentation for monthly consultant pharmacist medication regimen reports was reviewed. A statement on page 105 included. If no irregularities are found, consultant pharmacist also documents this and signs and dates such documentation. Additionally, the medical records contained no recommendations from the pharmacist and/or responses from the physician, regarding identified irregularities. Upon inquiry, it was discovered this information was only made available to the director of nursing and the administrator. It was also revealed this information was not placed on each resident's active record. Review of the facility's policies and procedures, regarding monthly medication regimen reviews (llA1), revealed the findings of the medication reviews were to be provided .to the director of nursing or designee and documented and stored with the other consultant pharmacist recommendations in the resident's active record. | 2017-02-01 |