cms_WV: 9601
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9601 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 323 | D | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's request/concern forms, and staff interview, the facility failed to follow orders for a safe transfer of a resident and failed to ensure the necessary equipment was available to facilitate a safe transfer. This was true for one (1) of three (3) residents whose medical records were reviewed for accident hazards. Resident identifier: #83. Facility census: 89. Findings include: a) Resident #83 Review of the facility, Request / concern forms, found Resident #83 had alleged that staff would not transfer him out of bed to the bed side commode with the lift because the lift pad (sling) was locked in the laundry room and there were no staff present to unlock the laundry door. The concern was dated 08/26/12 and was completed by the director of nursing (DON). Further review found a statement attached to the allegation and addressed to the director of nursing (DON) from a registered nurse, Employee #81. Per our phone call - I explained to (name of Resident #83) and his sister due to the lift pad being in laundry we would not be able to physically lift to bedside commode. Upset because on 08/25/12 three CNAs were instructed to assist to BSC (bedside commode), he is total lift. Bedpan offered several X's (times) refused. Verbalized comfort except wants on BSC. This statement was not dated. A follow up statement to the DON on the same paper, Laundry had sling clean and on shelf if open or access this entire ordeal could have been avoided. Included in the investigation was a statement from Employee #25, medical records staff. (Name of staff, Employee #80 a nursing assistant) came to me (name of medical records employee) and stated that (name of resident) needed to go to the bathroom, and that (first name of another employee) would not take him. I went to activities where (first name of employee) was feeding another resident (name of resident) and told her that when a resident ask (sic) to go to the bathroom we take them. I then told her to help (name of Employee #80) put him on bed side commode and I would finish feeding. The statement was dated 08/27/12 with the notation, This happened on Saturday 08/25/12. Employee #55, a nursing assistant, provided the following statement. The report I got from the off going CNA (certified nursing assistant) was that we are to get (resident's room number) up with assist. That all I had to do was help him stand and to turn him around on the bedside commode and that I had to have another CNA in the room with me to help. The statement was dated 08/26/12 with a, date of this 08/25/12. On 10/03/12 at 4:00 p.m., Employee #15, the MDS (minimum data set) coordinator provided a copy of the resident's care plan which she verified was in effect when the incident occurred. Resident #83 required a mechanical lift and two (2) employees for transfers. Instructions of the request concern form were, Please list the two things we can do for you immediately to satisfy this request or concern. 1. Order a extra lift pad to have when one is being laundered. 2. Educated staff on lift policy and to notify charge nurse on how resident transfers from bed. 3. Key placed on east/west wing to laundry room if needing to get into room. The DON was interviewed on 10/03/12 at 2:45 p.m. At first she said the wrong statements were with the complaint and that the lift pad issue happened weeks ago. The DON was reminded the resident was admitted to the facility on [DATE]. She could not explain how the dates of the statements coincided with the date of the complaint made by the resident. She did state that Employee #25, the medical records clerk, was the manager on duty and she was also a licensed practical nurse. The DON verified the resident was a two (2) person assist with a mechanical lift and that the statements provided indicated the lift was not used to transfer the resident to the bedside commode because the needed lift sling was not available. She stated the nursing assistants were following the orders of a supervisor and these orders were in conflict with his current plan of care for transfer requirements. | 2015-10-01 |