cms_WV: 9163
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9163 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-01-23 | 224 | G | 1 | 0 | 71W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were free of neglect by failing to assess, monitor, and provide medical intervention timely, for an [AGE] year old resident with diabetes and an existing pressure ulcer when she developed a blackened area on her right great toe. There was no evidence of assessments or interventions until six (6) days after the initial identification. This delay had the potential to adversely affect the progression of the wound and comfort of the resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 This [AGE] year old resident had [DIAGNOSES REDACTED]. She also had a had been receiving treatment for [REDACTED]. A progress note, dated 12/13/12, by Employee #126, a licensed nurse, identified the family's concern with the resident's great toe on the right foot. The nurse assessed the area, and noted a dark purple hematoma on toe. No evidence of any additional assessment or monitoring of the changes to the right great toe were found until six (6) days later on 12/19/12 at 5:47 a.m. On 12/19/12 at 5:47 a.m., a registered nurse (Employee #1), documented Resident has blackened area on right great toe and 4th great toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . No dorsal or post tibia pulse appreciated with Doppler. Left foot has sore on 2nd toe . Will report to MD (doctor). In an interview with Employee #126, on 01/23/13 at 8:50 a.m., she said she had faxed the physician about the right great toe on 01/13/12, and verbally passed the information to the oncoming shift. She said the right great toe looked purple, it seemed to have been a sudden change, and had given the appearance of perhaps having been bumped. Employee #82 (registered nurse) was interviewed on 01/23/13 at 9:05 a.m. She said they kept copies of faxes sent to the physician in the physicians' mailboxes until they received a response. They would re-fax the physician if there was no response. All resolved faxes were filed in a book at the desk. This book was thinned on occasion when it was getting larger, and the older ones were shredded. Review of the resolved fax book, on 01/23/13 at 9:10 a.m., found the faxes in the book only went back to 12/20/12. An interview with the director of nursing (DON), on 01/23/13 at 1:45 p.m., revealed the first time the condition of the resident's right great toe had been placed on the 24-hour report was on 12/19/12. This was after Employee #1 had written the entry about the condition of the resident's toe and noted to call the doctor. The DON said an appointment was then made with the podiatrist, who saw the resident on 12/19/12 at 4:45 p.m. She could find no evidence to support a physician had been notified, or had evaluated the toe, between 12/13/12 and 12/19/12. The podiatrist's progress note, dated 12/19/12, noted Resident #119 had dry gangrene of the right hallux (big toe). He recommended the resident be seen by an orthopedic physician as soon as possible. According to the resident's record, her medical power of attorney had made an appointment for 12/27/12 with an orthopedic surgeon. However, due to an increase in the resident's level of pain, she was sent to a local hospital on [DATE], at which time she was admitted . According to a 12/25/12 nursing progress note, the resident was transferred for pain evaluation due to uncontrolled pain in the right lower leg. Review of the admitting hospital's medical records, revealed that upon admission the resident was found to have avascular (having few or no blood vessels) right great toe with a lot of pain and color changes, and gangrene due to secondary diabetes mellitus. An orthopedic consultation dated 12/16/12 revealed an impression of dry gangrene, right foot, and a recommendation for a BKA ([MEDICAL CONDITION]) right lower extremity. She underwent a right [MEDICAL CONDITION] on 12/27/12. Resident #119 had been admitted to the facility in November 2012 with a Stage II pressure ulcer to the right heel. This was the same foot on which the great toe had a blackened area. Record review found the absence of a weekly body audit on 12/11/12, with the most recent body audit having occurred on 12/04/12, and the next on 12/17/12. Neither noted the condition of the right great toe. Record review also found the absence of a weekly measurement and assessment of the pressure ulcer to the right heel on 12/20/12, with the most recent one having occurred on 12/13/12, and no other prior to her transfer to the hospital on [DATE]. Interview with licensed nurse Employee #81, on 01/22/13 at 9:30 a.m., found that every resident was to have a skin audit done weekly. Although they were usually done by the treatment nurse, the floor nurses were to do them in the absence of the treatment nurse. During an interview with the Director of Nursing (DON), on 01/22/13 at 2:45 p.m., she produced weekly body audit sheets dated 12/04/12 and 12/17/12 for Resident #119. She was unable to locate a body audit sheet for 12/11/12 at that time, or prior to exit. She said that body audits were to be done weekly. | 2016-01-01 |