cms_WV: 9201
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9201 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 272 | E | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility's interdisciplinary team failed to complete assessments to accurately reflect each resident's health status / condition for six (6) of thirty-eight (38) Stage II sample residents. Complete and accurate assessments were not conducted for Resident #223's pressure ulcer, Resident #129's indwelling catheter, Residents #116 and #199's bladder continence, Resident #155's dental status, and Resident #125's complaints of a sore toe. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #223 During a review of Resident #223's initial Medicare 5-Day minimum data set assessment (MDS), with an assessment reference date of 04/14/11, found this resident had a pressure ulcer measuring 2.5 cm x 3.4 cm. This pressure ulcer, which was noted to have been present on admission to the facility, was identified on the MDS as being unstageable due to the presence of slough or eschar. Further review of the MDS found in Section V that the care area of Pressure Ulcer was then triggered and addressed in the care plan. The assessor noted that the further information for this care area could be found in a worksheet dated 04/18/11. The Care Area Assessment (CAA) worksheet dated 04/18/11, when reviewed, found in the analysis of this ulcer that this represented a potential problem. The nature of the problem was stated: At risk for pressure ulcers. The end note stated: (Resident #223) could be at risk for a pressure ulcer related to impaired mobility and incontinent. See the plan of care documentation for 4/11/2011. The staff will continue to assist her as needed for frequent position changes as well as prompt incontinence care. Any concerns with her skin will be reported to the MD promptly. Will proceed to care plan. This CAA did not reflect the resident's actual condition or evaluate the causative factors or the care needs for the pressure area that was already present. It addressed only the potential for developing pressure sore, when the medical record and skin assessments indicated she had actual skin breakdown. During an interview with Employee #173 (registered nurse (RN) - case mix consultant) at 3:15 p.m. on 06/06/11, she was questioned about the CAA note not providing additional information about the pressure ulcer. She stated that they sometimes write the CAA notes in a manner not to repeat what is already specified in the MDS assessment; for example, since the wound measurements were already there, they would not write them again. She verified the CAA note addressed this ulcer as a potential problem and did not identify that the resident had an actual pressure ulcer at the time this assessment was completed. -- b) Resident #129 Record review revealed Resident #129 was admitted to the facility on [DATE] with an order for [REDACTED]. Resident #129's admission MDS, with an ARD of 03/11/11, revealed this resident had an indwelling urinary catheter. This triggered the care area Urinary Incontinence and Indwelling Catheter in Section V of the MDS, where the assessor recorded that the location and date of the CAA could be found in the worksheet dated 03/16/11. The resident's CAA worksheet for Urinary Incontinence and Indwelling Catheter, when reviewed, stated that there was a potential problem. When describing the nature of the problem / condition, the assessor noted the resident had a Foley indwelling urinary catheter in place and needed assistance with toileting. There was no discussion of why the catheter was needed. In the section for discussing the summary and care plan considerations, the assessor recorded: Resident has a Foley catheter in place as evidenced by the order dated 3/5/11. This could place her at risk for problems such as altered urinary output, pain etc. She needs assistance with toileting as evidenced by the documentation in the POC (plan of care). Staff will continue to assist her with toileting and catheter care to help minimize the risk of problems. Any problems noted or reported will be addressed with the MD. Will continue to care plan. There was no information in this resident's medical record discussing why she had this indwelling catheter, when it had been inserted, or whether there was any consideration to remove the catheter. During an interview on the afternoon of 06/04/11, Employee #88 (RN - assistant director of nursing) verified the reason for this catheter was excoriation, which was present on admission. This excoriation was resolved on 04/04/11, and there was no evidence of an assessment to determine whether a continued need for this indwelling catheter existed. -- c) Resident #116 The resident's annual MDS, with an ARD of 02/01/11, indicated the resident was always continent of urine. The quarterly assessment, with an ARD of 04/20/11, indicated she was occasionally incontinent of urine. Neither assessment was coded to indicate the resident was on a urinary toileting program. A physician's progress note, dated 05/19/11, stated the resident . C/O (complained of) new onset incontinence - sudden, no urge or control 'I don't know what's wrong.' The physician also noted the resident was alert and oriented. A urinalysis and a urine culture and sensitivity were ordered on [DATE]. These were completed on 05/20/11. An antibiotic was ordered for the identified urinary tract infection. No evidence was found in the nurses' notes of any complaints having been made by the resident of any urinary elimination problems. There was no evidence of monitoring to determine the effectiveness of the antibiotic in relieving the resident's complaints of urgency and loss of bladder control. On 06/03/11 at 9:30 a.m., the resident was interviewed regarding her bladder function. She stated, Sometimes I need to go when I need to go and Sometimes I can't make it. The resident stated there had been some improvement since she was given the antibiotic, but she still had times when she needed to go right away. On 06/03/11 at 10:34 a.m., Employee #95 (RN), when asked about the resident's urinary continence status, said the staff had talked about possibly seeing if the resident would wear an incontinence brief at night. He was unable to find any evaluation of the change in her continence status. Employee #69 (nursing assistant), when asked about the resident's urinary continence in mid-morning on 06/07/11, said she had been reporting the resident's incontinence for about four (4) weeks. She demonstrated how the nursing assistants could put issues in the care tracker to alert the nurse. She said she had asked about whether the resident could have an incontinence brief at night. The nursing assistant also said it had been discussed whether the perimeter mattress kept the resident from getting out of bed at night. On the afternoon of 06/07/11, the director of nursing (DON - Employee #12) was asked whether there was any evidence of an evaluation of the resident's continence status. On the morning of 06/08/11, she reported she had not found anything. There was no evidence the decline from always continent to occasionally incontinent of urine had been assessed in an attempt to identify any contributing / causal factors, in an effort to restore or to prevent further decline in her urinary continence. -- d) Resident #199 The resident's admission MDS, with an ARD of 02/11/11, indicated the resident was frequently incontinent of urine. He was noted to remain frequently incontinent of urine on the quarterly MDS with an ARD of 04/29/11. No evidence of an assessment for voiding patterns or possible causal factors for his incontinence was found. On the late afternoon of 06/07/11, the DON was asked for evidence of an assessment of his urinary continence. A significant change in status assessment (SCSA) MDS, with an ARD of 05/27/11, was reviewed. This assessment indicated he required extensive assistance for toilet use, that he could walk in his room independently, and needed supervision when walking in the hall. He was coded as being able to be understood and could understand others. On 06/08/11 at approximately 1:00 p.m., the CAA for urinary incontinence, completed for the SCSA, was reviewed. The CAA noted the resident required extensive assistance with toilet use and he was frequently incontinent. The form used by the facility for completion of the CAA included a section for identifying the type of incontinence. The choices were stress, urge, mixed, overflow, transient, and functional. None of these were checked. Under the section of the CAA for Care Plan Considerations, the assessor had checked to avoid complications, maintain current level of functioning, and to minimize risks as the overall objectives. Improvement and Slow of minimize decline were options, but neither had not been checked. The narrative for the CAA stated: Resident is frequently incontinent of urine and needs assist with toileting as evidenced by the documentation in POC. This places him at risk for problems such as skin break down and infections. Staff will continue to asist (sic) him as needed with continent (sic) care to help minimize the risk of problems. Any noted will be addressed with the MD. Will continue to care plan. His [DIAGNOSES REDACTED]. None were indicative of a condition that would prohibit an attempt to improve his urinary continence status. The CAA had a section for diseases and conditions that might affect continence, but none were checked. In an interview with the resident on 06/08/11 at 11:10 a.m., he said he usually knew when he had to void. The CAA verbiage used by the facility was the same as the CAA in Appendix C of CMS's RAI Version 3.0 Manual. The instructions in Appendix C included: Step 4: . provide supporting documentation regarding the basis or reason for checking the item, including the location and date of that information, symptoms, possible causal and contributing factor(s) for that item, etc. Step 5: Obtain and consider input from resident and/or family/resident's representative regarding the care area. Step 6: Analyze the findings in the context of their relationship to the care area. This should include a review of indicators and supporting documentation, including symptoms and causal and contributing factors, related to this care area. Draw conclusions about the causal/contributing factors and effect(s) on the functional ability of the resident, and document this information in the Analysis of Findings section. There was no evidence these steps had been taken in an attempt to assess the resident's potential to have an improvement in his urinary continence status, or to prevent further decline if improvement was not possible. -- e) Resident #155 Medical record review revealed this [AGE] year old male resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. During two (2) interviews with the resident - on 05/25/11 at 8:46 a.m. and again on 05/31/11 at 11:20 a.m., the resident stated his teeth hurt, especially when eating. He related he had about seven (7) teeth and they were rotted out. On 06/01/11 at 2:00 p.m., the DON stated she could find no evidence of a dental assessment and no evidence the resident had been evaluated by a dentist since his admission on 11/18/09. Another review of the medical record, on 06/01/11, revealed a nursing admission evaluation completed 10/08/10. Section F, regarding the resident's condition of teeth, indicated the resident had broken teeth. On 06/02/11 at 3:00 p.m., Employee #95 (RN - director of care delivery) was asked to assess the resident's dental needs. Employee #95 assessed the resident's teeth and stated, Looks like he may have a cavity in that back tooth. The resident's MDS with an ARD of 11/10/10, when reviewed, did not indicate the resident had any oral problems under Section L (L0200 - Oral / Dental Status). The response to this section was: None of the above was present. Since the resident had broken teeth the facility should have chosen the response: Obvious or likely cavity or broken natural teeth. -- f) Resident #125 During Stage I of the survey, on 05/25/11 at 2:20 p.m., this resident stated he had pain with no relief. When asked to describe, the resident said the toe beside his great toe on his right foot had a sharp nail (toenail). The resident stated the podiatrist, who trimmed his toenails, left it like that. The resident stated it hurt to walk, so he had been avoiding walking due to the pain. When asked if he had informed facility staff of this problem, he said, I let three (3) or four (4) people know. Review of the resident's medical record, during Stage II of the survey on 05/31/11, revealed no evidence the facility had assessed or addressed this resident's sore toe. An interview was conducted with Employee #58 (licensed practical nurse) at 9:00 a.m. on 06/01/11. Upon inquiry, Employee #58 stated the resident was very compliant with care and allowed staff to care for his needs. When asked about the sore toe, Employee #58 stated she had not been made aware of the resident's sore toe. At 10:45 a.m. on 06/01/11, the resident's right toe was observed with Employee #58. During the observation, the resident stated this toe had been hurting a lot. Employee #58 confirmed there was a sharp toenail on the toe beside his great toe on his right foot. At this time, the resident was asked again if he had let anyone know about this sore toe. The resident stated, I let three (3) or four (4) of them know. On 06/02/11 at 10:30 a.m., an interview was conducted with the DON. Upon describing the resident's sore toe and his statements that he told nursing staff about the problem, the DON stated the resident was competent and she felt his statements (regarding telling staff about his sore toe) were credible. At the time of the survey, the facility had not assessed the resident's sore toe to determine the extent of the problem and/or to determine the appropriate care and services needed to address the problem. | 2016-01-01 |