cms_WV: 9382
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9382 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 280 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed, for three (3) of twenty-eight (28) Stage II sample residents, to ensure each resident's comprehensive care was was revised when changes occurred with the resident condition and/or treatment plan. Resident #23's care plan was not revised to reflect the presence of a second pressure ulcer. Resident #112's care plan was not revised to reflect changes made to her therapeutic diet. Resident #12's care plan was not revised when interventions to prevent falls / promote safety were no longer in use. Resident identifiers: #23, #112, and #12. Facility census: 112. Findings include: a) Resident #23 Medical record review, on 06/07/10, revealed Resident #23 two (2) Stage II pressure ulcers, one (1) on each buttock. A physician order, dated 06/01/10, directed staff to cleanse the area on the right buttock with sterile normal saline, apply Skin integrity to the wound, and cover with [MEDICATION NAME] foam every day, and check every shift for placement. Another physician's orders [REDACTED]. An observation of these ulcerations, on the morning of 06/10/09, found two (2) Stage II ulcerations - one (1) on the right side of the coccyx and one (1) on the left side of the coccyx; the surrounding tissue was pink, and serosanguinous drainage was seeping from the wounds. On 06/14/10 at 11:00 a.m., Resident #23 was interviewed in her room. During this interview, she reported she had pain when she sits up in the chair, especially if she sits up too long, and this was one (1) of the reasons why she did not like to get up into the chair. On 06/14/10 at 11:42 a.m., two (2) nurses (Employees #142 and #95) were interviewed at the nurses' station. They both identified the resident's family brings snacks to the facility, the resident often snacks in her room, and they have done a lot of education with the family to bring in healthy snacks. Additionally, they identified that Resident #23 does not like to get up in the chair, and these issues contributed to delays in healing for this resident. Review of the resident's care plan found the interdisciplinary team, on 12/19/06, identified Resident #23 was at risk for skin breakdown. Her care plan was updated on 06/02/10, to address the presence of an open area on the resident's right buttock. The plan was not revised to address the presence of a pressure area on the resident's left buttock. The plan addressing the wound on the right buttock identified as a goal: Resident will show significant improvement to open area on coccyx by the next review. Interventions to attain this goal included: Dress area per MD ordered, Braden scale every week times four (4), body audit per licensed nurse every day, and wound will be assessed and measured weekly. Aside from dressing the area as ordered, none of these interventions would result in attainment of the goal. Additionally, the plan was not revised to address the issues identified by the nurses (e.g., refusal to get up in a chair, eating unhealthy snacks throughout the day). b) Resident #112 A review of Resident #112's clinical record revealed the previous three (3) minimum data set assessments indicated, in Section K1, the resident had both chewing and swallowing difficulties and the resident was on altered consistency diet. A review of the physician's orders [REDACTED]. The care plan, revised on 06/01/10, stated the resident was to receive nectar liquids and it did not include interventions regarding monitoring for choking / aspiration related to her new order to receive regular, unthickened liquids. During an interview with the minimum data set (MDS) coordinators (Employees #1 and #120) at 2:45 p.m. on 06/13/10, they acknowledged Resident #112's care plan did not address the changes made to the resident's diet and consistency of liquids, and they acknowledged that the resident's information sheet (used by the nursing assistants when rendering care) had not been updated. c) Resident 12 A review of Resident #12's medical record, on 06/14/10 at 10:00 a.m., revealed the resident had not been ambulatory since at least 12/19/09, as documented on a quarterly minimum data set (MDS) of that date. However, review of her current care plan found it still contained an approach to address the potential for falls by encouraging and assisting the resident to wear proper and non-slip footwear. Also, the current care plan contained an approach for bed bolsters to reduce the potential for falls, although the use of the bed bolsters was discontinued on 04/05/10. During an interview with Employee #120 on 06/14/10 at 10:45 a.m., she confirmed these approaches were no longer appropriate for the resident and had not been removed from the resident's active care plan. | 2015-11-01 |