cms_WV: 8646
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8646 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2011-08-17 | 279 | D | 0 | 1 | 5VE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility's interdisciplinary team failed to develop comprehensive care plans to address each resident's care needs and to describe the services to be provided to prevent complications, address therapeutic diet restrictions, address behaviors and maintain a safe environment. The care plans were not complete and/or did not provide instructions to provide care in the areas of dental needs, nutritional status, behaviors, and infection control for three (3) of forty-seven (47) Stage II sampled residents. Resident identifiers: #1, #138, and #20. Facility census: 89. Findings include: a) Resident #1 Review of Resident #1's medical record revealed this [AGE] year old male was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. For Resident #1, the facility failed to develop a comprehensive care plan providing instruction in the following areas: dental care, nutrition, and behaviors. 1. Dental Care Review of the resident's minimum data set assessment (MDS), with an assessment reference date (ARD) of 07/06/11, found the resident triggered for further review in the area of dental care. The Care Area Assessment (CAA) worksheet dated 07/18/11, when reviewed, found the nature of the problem described as follows: Resident has some or all natural teeth lost, potential for dental problems. The care plan considerations were: Will proceed to care plan to minimize risks and avoid complications such as decreased po (oral) intake, weight loss, or pain. The most recent care plan addressing oral care originated on 08/10/09. The care plan problem stated (quoted as typed): Self-care defecit, dependent on staff for all ADL functions of bathing, dressing, toileting and personal hygiene. The goal associated with this problem was (quoted as written): Resident will continue to function at current level thru next review. The only approach associated with dental care was: Staff to assist with oral care daily - 5/11/11. The care plan failed to discuss how the resident's dental needs could affect PO (oral) intake, weight loss, and pain as written on the CAA worksheet. The employee who completed the MDS was no longer employed at the facility; therefore, the care plan addressing dental needs was discussed with the director of nursing on 08/11/11 at 2:45 p.m. and again on the morning of 08/16/11. No further information was provided by this employee. 2. Nutritional status Review of Section K in the most recent MDS, an annual assessment with ARD of 07/06/11, revealed the resident was receiving a mechanically altered diet and had loss of liquids / solids from the mouth when eating or drinking and coughing or choking during meals. Further review of the resident's care plan revealed the following problem, which was initiated on 07/12/11 (quoted as typed): Swallowing Difficulty as evidenced by: Abnormal Swallow Study. Approaches included: Diet as ordered. Educate patient and caregiver on the following safe swallow strategies: (list) (note that no strategies were listed). Monitor of S/Sx (signs and symptoms) of aspiration. Monitor meal consumption. Monthly weights. Proper positioning at meals. Provide thickened liquids as ordered. Provide thickened liquids between meals. Take patient to dining room for meals. Review of the physician's orders [REDACTED]. Special instructions: Do not send rice, corn or hard fruit and vegetables. During an interview with the facility's registered dietician (Employee #101) on 08/15/11 at 12:30 p.m., she was asked why the resident's specific diet was not listed on the care plan with the special instructions. She stated the care plan did state the resident would receive thickened liquids. She also stated, We just list a regular diet in case the diet changes. The care plan failed to include the the type of diet to be served, the consistency of the thickened fluids, and the special instructions for food items that should not be served to the resident. 3. Behaviors Review of the resident's care plan revealed three (3) current problems addressing behaviors (all quoted as written): - 05/22 (no year listed) - History of sexual behavior (resident to resident) sometimes has angry outbursts and may strike out at staff. - 05/14/11 - hit & grabbed other resident in Hallway. - 07/17/10 - Hx (history of) sexual behavior towards female resident. The goal for all three (3) problems was (quoted as typed): Resident to have needs met and have no decline in psychosocial well being / behavior related to cognitive impairment AEB (as evidenced by) staff documentation. This goal was not stated in measurable teems. The DON, when interviewed on 08/11/11 at 2:45 p.m., was unable to explain how the resident's goal was to be measured and was unable to present any further information on the matter. -- b) Resident #138 Medical record review revealed a [AGE] year old male admitted to the facility on [DATE]. Current active [DIAGNOSES REDACTED]. A clinical health status, completed by a licensed nurse upon admission on 07/13/11, identified the resident had broken loose or carious teeth. Review of the resident's admission MDS, with an ARD date of 07/20/11, failed to accurately reflect the resident's dental status; the MDS stated the resident had no dental issues. On 08/04/11, an oral health screening tool was completed by a registered nurse (RN), which noted the resident had teeth that were broken, decayed, and covered with plaque. In the comments section, the RN wrote: Front teeth have black decay in center of teeth, unable to see how many teeth are missing due to resident did not open mouth real wide. Under recommendations, the RN noted the need to were to refer the resident to a dentist for decayed teeth. Review of the care plan revealed the following problem (quoted as typed): (Name of resident) is a new admission to the facilitity and requires staff assistance r/t (related to) self care deficit secondary to [MEDICAL CONDITION], dementia, being HOH (hard of hearing), Ataxia, Depression, Anxiety and [MEDICAL CONDITION]. The only approach addressing dental needs was: Provide oral care qd (every day) in am (morning) and prn (as needed) after meals and at hs (hour of sleep) with toothbrush and toothpaste. This was the only time the resident's oral / dental care needs were addressed in the care plan. The care plan also contained a problem of (quoted as typed): Inadequate Oral Food / Beverage Intake due to: Alcoholism, Food and beverage intake less than required. The care plan did not identify how the facility was going to address his need for a dental consult or how his dental needs could affect his ability to consume meals, cause pain, etc. The DON, when interviewed on 08/11/11 at 2:45 p.m., was unable to provide any further information related to the care plan. On the morning of 08/17/11, the DON stated the facility had scheduled a dental consult. -- c) Resident #20 Observation, on 08/08/11 at approximately 4:00 p.m., found this resident sitting up in a chair in her room. A sign was posted on the wall above the head of her bed for contact precautions. On 08/09/11 at approximately 8:00 a.m., Employee #61 (the assistant director of nursing - ADON) stated the resident had [DIAGNOSES REDACTED] ([MEDICAL CONDITION]). A repeat observation of Resident #20's room, on 08/10/11, found the signage had been removed. On 08/15/11, the resident had once again been placed on contact precautions. On 08/16/11, the resident was observed out and about in the hall in her wheelchair. According to the director of nursing (DON), the resident's last stool culture had come back negative. They were keeping her on precautions a little longer to make sure she did not have any further symptoms. Review of the resident's care plan, established on 07/15/11, found it did not address the isolation needs / limitations. The problem was: Res (resident) has[DIAGNOSES REDACTED] Contact Isolation. The interventions were: 1) Adm (administer) meds as ordered. Encourage as she will refuse. 2) Stool samples as ordered. 3) Notify MD for s/s (signs/symptoms) Dehydration or complications. 4) Contact isolation. The care plan did not address to what extent the contact precautions should or should not limit this individual's activities. For example, there were no instructions to direct caregivers to ensure the resident washed her hands well before leaving her room or whether the resident's movements should be restricted if she was actively having diarrhea, etc. | 2016-04-01 |