cms_WV: 853
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 853 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 641 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility failed to ensure the Minimum Data Sets (MDS)s accurately reflected the resident's status. This was true for five (5) of forty-one (41) resident's MDSs reviewed during the Long-Term Survey Process (LTCSP). Resident #113's MDS was inaccurate in the area of prognosis/death in the facility. Residents #91 and #92's MDS was inaccurate in area of nutritional/weight loss status. Residents #103 and #3's MDS was inaccurate in area of medication. Resident's identifiers: #113, #91, #92, #103 and #3. Facility census: 117. Findings included: a) Resident #113 Resident #113 was admitted to the facility on [DATE] from an acute care facility. Resident's [DIAGNOSES REDACTED]. Review of the attending physicians' progress note dated, 03/01/19 at 2:41 pm, states, . Prognosis is terminal, with a predicted survival of less than three (3) months . Review of the admission MDS with an assessment reference date (ARD) of 03/07/19. Review of section J 1400 Prognosis was marked to indicate the resident did not have a condition or chronic disease that may result in a life expectancy of less than six (6) months. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 06/27/19 at 11:00 am, confirmed the resident had was terminal and the MDSs with ARD of 03/07/19 inaccurately coded. They both agreed the MDS should have been coded, Life expectancy of less than six (6) months. b) Resident #91 Medical record review for Resident #91, found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Admission nursing assessment reviewed, no weight and/or height was obtained. Review of the admission MDS with ARD of 06/07/2019 under section K lists the weight as 128. Nutritional care plan for Resident #91 was initiated on 06/07/19 as follows: -- Focus: Resident is a potential nutritional concern related to (r/t) fair po (by mouth) intakes, [DIAGNOSES REDACTED]. -- Goal: No significant weight changes through next review. (MONTH) experience some weight fluctuations based on diuretic ([MEDICATION NAME]) treatment in place. --Interventions: Proheal (protein supplement) as ordered. Honor food preferences within meal plan. Weigh as ordered/needed and alert dietician and physician to any significant loss or gain. Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain and abnormal labs) and report to food and nutrition/physician as indicated. Monitor intake at all meals, offer alternate choices as needed, alert dietician physician to any decline in intake. Provide diet as ordered Offer snacks. --On 06/08/19, a nutritional assessment for Resident #91, completed by the Registered Dietician (RD) with no weight and/or height recorded. Under nutritional history reads: .No height/weight available at time of assessment Review of Resident #91's weight and vitals summary found resident's height and weight was obtained on 06/11/19 at 6:35 pm. Weight 127.8 and Height 59 inches. Facility's weight and height policy reviewed and found: Patients are weighed upon admission and/or re-admission, then weekly for four (4) weeks and monthly thereafter. Patients height will be measured upon admission, re-admission, and annually and recorded in Point Click care (PCC). Purpose: To obtain baseline weight and identify significant weight change. To determine possible causes of significant weight change. To obtain baseline height. Review of the Resident Assessment Instrument (RAI) found the following steps on assessment and coding instructions on the MDS regarding height and weight: -- Steps for Assessment for K0200A, Height 1. Base height on the most recent height since the most recent admission/entry or reentry. Measure and record height in inches. 2. Measure height consistently over time in accordance with the facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record. If the last height recorded was more than one year ago, measure and record the resident's height again. --Steps for Assessment for K0200B, Weight 1. Base weight on the most recent measure in the last 30 days. 2. Measure weight consistently over time in accordance with facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD of this assessment. 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. 5. If the resident's weight was taken more than once during the preceding month, record the most recent weight. Interview on 07/02/19 at 11:10 am, with the Director of Nursing (DON) found the weight entered on Resident #91's admission MDS assessment with the ARD of 06/07/19 was not obtained until four (4) days after the ARD date and should not have been used. She confirmed the resident's height and weight on admission and/or readmission should be obtained within 24 hours of admission/readmission. She also confirmed weights used on the MDS should be obtained prior to the ARD date. c) Resident #92 Medical record review for Resident #92, found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Admission nursing assessment reviewed, no weight and/or height was obtained. On 06/06/19, a nutritional assessment for Resident #92, completed by the Registered Dietician (RD) with no weight and/or height recorded. Under nutritional history reads: .No height/weight available at time of assessment Nutritional care plan for Resident #92 was initiated on 06/07/19 as follows: --Focus: Resident is a potential nutritional concern related to (r/t) [DIAGNOSES REDACTED]. --Goal: No significant weight changes through next review. -- Interventions: Honor food preferences within meal plan. Weigh as ordered/needed and alert dietician and physician to any significant loss or gain. Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain and abnormal labs) and report to food and nutrition/physician as indicated. Monitor intake at all meals, offer alternate choices as needed, alert dietician physician to any decline in intake. Provide diet as ordered Offer snacks. Review of Resident #92's admission MDS with ARD of 06/08/2019 under section K lists the weight as 180. Review of Resident #92's weight and vitals summary found resident's height and weight was obtained on 06/12/19 at 1:25 pm. Weight 180.2 and Height 67 inches. Facility's weight and height policy reviewed and found: Patients are weighed upon admission and/or re-admission, then weekly for four (4) weeks and monthly thereafter. Patients height will be measured upon admission, re-admission, and annually and recorded in Point Click care (PCC). Purpose: To obtain baseline weight and identify significant weight change. To determine possible causes of significant weight change. To obtain baseline height. Review of the Resident Assessment Instrument (RAI) found the following steps on assessment and coding instructions on the MDS regarding height and weight: --Steps for Assessment for K0200A, Height 1. Base height on the most recent height since the most recent admission/entry or reentry. Measure and record height in inches. 2. Measure height consistently over time in accordance with the facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record. If the last height recorded was more than one year ago, measure and record the resident's height again. --Coding Instructions for K0200A, Height o Record height to the nearest whole inch. o Use mathematical rounding (i.e., if height measurement is [MEDICAL CONDITION] inches or greater, round height upward to the nearest whole inch. If height measurement number is [MEDICAL CONDITION] to [MEDICAL CONDITION] inches, round down to the nearest whole inch). For example, a height of 62.5 inches would be rounded to 63 inches and a height of 62.4 inches would be rounded to 62 inches. --Steps for Assessment for K0200B, Weight 1. Base weight on the most recent measure in the last 30 days. 2. Measure weight consistently over time in accordance with facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD of this assessment. 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. 5. If the resident's weight was taken more than once during the preceding month, record the most recent weight. Interview on 07/02/19 at 11:10 am, with the Director of Nursing (DON) found the weight entered on Resident #92's admission MDS assessment with the ARD of 06/08/19 was not obtained until four (4) days after the ARD date and should not have been used. She confirmed the resident's height and weight on admission and/or readmission should be obtained within 24 hours of admission/readmission. She also confirmed weights used on the MDS should be obtained prior to the ARD date. d) Resident #3 Review of Resident #3's physician's orders [REDACTED]. On 03/06/19, Resident #3 was receiving [MEDICATION NAME] 2 mg at bedtime when the consulting pharmacist recommended a gradual dose reduction (GDR) of the medication. The physician agreed with the pharmacist's recommendation and on 03/12/19 an order was written for [MEDICATION NAME] 1 mg at bedtime. Resident #3 experienced an increase in her depressive symptoms. On 05/13/19, Resident #3's [MEDICATION NAME] was increased to 2 mg at bedtime. Resident #3 continued to experience an increase in her depressive symptoms. On 05/20/19, Resident #3's [MEDICATION NAME] was increased to 5 mg at bedtime. Resident #3's Minimum Data Set (MDS) with Assessment Resident Date 06/18/19, Section N, Item N0410, A, Medications Received, stated the resident received antipsychotic medication seven (7) of the last seven (7) days. Section N, Item N0450, A, Antipsychotic Medication Review, stated the resident had not received antipsychotic since the prior assessment. Due to this response, Item N0450, B, regarding whether a GDR was attempted was not answered. During an interview on 06/26/19 at10:22 AM, the Director of Nursing (DoN) stated Section N, Item N0450, A, was completed incorrectly. She stated this item should have stated Resident #3 had received antipsychotics, and the information regarding the GDR should have been completed. No further information was received before the completion of the survey. e) Resident #103 During the survey, a review of Resident #103's most recent comprehensive Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/10/19 found that Resident #103 had received antipsychotic medications seven (7) out of seven (7) days during the assessment's look-back period. This information was recorded in box N0410 of the MDS. A review of Resident #103's Medication Administration Record [REDACTED]. However, box N0450 of the MDS was coded No - Antipsychotics were not received. During an interview on 07/01/19 at 10:33 AM, the facility's Director of Nursing (DoN) agreed that box N0450 had been coded incorrectly. No further information was provided prior to the end of the survey. | 2020-09-01 |