cms_WV: 9420
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9420 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2011-03-02 | 280 | D | 0 | 1 | 3LT211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to recognize continued weight loss for one (1) of twenty-eight (28) Stage II sample residents. Resident #14 was admitted to this facility on 12/30/10 with a weight of 186 pounds (#). The resident experienced a weight loss of 10# (5.38%) from 12/30/10 to 02/12/11. Review of the resident's comprehensive care plan (dated 12/30/10 to 03/31/11) found the care plan had not been reviewed / revised to address the weight loss. Resident identifier: #14. Facility census: 56. Findings include: a) Resident #14 Medical record review disclosed this resident had been admitted to this facility from an assisted living facility on 12/30/10, with medical [DIAGNOSES REDACTED]. The resident had been receiving Hospice services prior to admission. Further review of the record revealed this resident was 69 inches in height and weighed as follows: - 12/30/10 - 186# with a body mass index (BMI) of 27 - 01/12/11 - 177# with a BMI of 26 - 02/12/11 - 176# with a BMI of 26 The resident sustained [REDACTED]. The certified dietary manager (CDM - Employee #64) recorded a nutrition note on the resident's date of admission (12/30/10), after which there were no further nutrition notes entered by the CDM. The resident was on a regular diet. A dietary assessment was performed by a registered dietitian (RD) on 01/03/11. An initial assessment note by the RD, dated 01/12/11, stated to continue with the plan of care and to monitor for changes by facility staff. Review of the resident's current comprehensive care plan (dated 12/30/10 to 03/31/11) disclosed a problem of altered nutrition. The goal associated with this problem was to maintain optional nutritional status AEB (as evidence by) no significant weight loss greater than 5% a month. The interventions intended to achieve this goal included offering substitutes for uneaten foods and encouraging 100% consumption, offering snacks between meals, and documenting the resident's meal intake. Review of the resident's January 2011 meal intake records found the resident mostly ate 75-100% of meals and occasionally refused snacks, which were offered once a day. Review of the resident's admission minimum data set (MDS), with an assessment reference date of 01/05/11, revealed in Section V (the care area assessment (CAA) summary) that the potential problem area of nutritional status had triggered for further review and was to have been addressed in the resident's care plan. The location and date of the CAA information were notes to be in dietary flow sheets dated 12/30/10 and 01/05/11. Review of the monthly interdisciplinary conference meeting notes found no mention of the resident's weight loss or discussion of efforts to explore its possible causes. Review of the resident's comprehensive care plan found no revisions had been made to the resident's care plan regarding nutrition. Review of restorative notes disclosed entries dated 01/12/11, 01/19/11, 02/08/11, and on 02/21/11, with no indication of monitoring the resident's continued weight loss. During an interview on 03/01/11 at 10:45 a.m., the assistant director of nursing (ADON - Employee #4) confirmed the last dietary note made by the RD was the entry dated 01/12/11. The ADON also confirmed the resident's weight loss was not planned, the resident's weight had not been monitored, nor had the resident's care plan been revised when the weight loss continued. | 2015-11-01 |