cms_WV: 8185
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
8185 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 514 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of facility policy and procedure, the facility failed to ensure a permanent entry in the resident's medical record was not changed after being recorded. This was true for one (1) of seven (7) medical records reviewed during the complaint survey. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 Review of the resident's current care plan, located on the medical record, on 07/30/13 at 10:15 a.m. found a handwritten entry to the care plan, Deep tissue injury (DTI) to left buttocks surrounded by IAD (incontinence related [MEDICAL CONDITION]) related to immobility and incontinence, this entry was dated 07/29/13. On 07/30/13 at 10:30 a.m. the unit manager, Employee #47, was asked to make a copy of the resident's care plan. When she returned with the care plan, the original problem was no longer on the care plan. A new care plan problem had been written and dated 07/29/13, Deep tissue injury to left buttocks surrounded by MASD (moisture associated [MEDICAL CONDITION]) related to immobility. The surveyor found Employee #47 and Employee #34, a registered nurse, at the nurses station at 10:35 a.m. on 07/30/13. The surveyor spoke to both employees and asked who had changed the original care plan. Employee #34 stated she had re-written the care plan because it was incorrect. Employee #34 stated she saw the resident's DTI could not be due to incontinence because the resident had a catheter and a [MEDICAL CONDITION]. During the discussion with Employees #47 and #34, the director of nursing (DON) came to the nurses' station. The DON told Employee #34 she should have, yellowed out the problem and corrected it on the original copy. Employee #34 was asked for the original copy of the care plan and she said she could not find it. The DON found the original copy of the care plan in the trash can, torn into pieces. The DON stated she would tape the care plan together and give it to the surveyor. On 08/01/13 at 2:45 p.m. the DON provided a copy of the facility's policy for Clinical Records, Charting and Documentation. The policy directed staff to, . Draw a line through an error, write the correction above it, and date and initial the change. Never remove, use correction fluid or erase documentation. The DON confirmed the original care plan had been removed from the resident's chart on 08/01/13 at 2:45 p.m. , | 2016-07-01 |