cms_WV: 854
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 854 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 655 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop and implement a baseline care plan for Resident #111's to include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission and include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders [REDACTED]. Resident identifier: #111. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of policy for Falls Management reads: Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury This survey requested the statement from the nurse aide providing care for Resident #111 on 02/03/19 at 3:30 pm and neurological checks. No information was provided. emergency room report status [REDACTED]. No fractures or dislocations noted. Resident #111 was seen and examined by the attending physician on 02/04/19. Progress note states, She reports that yesterday she rolled out of bed onto her face during change and hit her face and knee. She was transferred to (name of hospital) where x-rays were done, and they were negative for fracture. She complains of severe pain around the left side of face Mild bruising and tenderness noted around the left periorbital area Resident was evaluated by physical and occupational therapy on 02/04/19. An assessment dated [DATE] at 1:59 performed by a registered nurse (RN) which indicates the resident requires extensive assistance of two or more persons for bed mobility. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed the licensed staff had not evaluated and developed a baseline care plan to include the assistance needed for bed mobility and no directions for care was provided to the direct care staff. No further information provided. | 2020-09-01 |