cms_WV
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172 rows where "filedate" is on date 2014-12-01
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10692 | 10692 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 157 | D | 1 | 0 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to immediately notify an interested family member when one (1) of forty-five (45) Stage II sample residents, who was alert and oriented, experienced an acute change in condition resulting in transfer to a local hospital emergency department. Resident identifier: #162. Facility census: 105. Findings include: a) Resident #162 On 08/08/11 at approximately 1:00 p.m., medical record review for Resident #162 revealed he had the capacity to make his own medical decisions. The review also revealed two (2) nursing notes pertaining to an acute change in the resident's physical condition. - A nursing note, dated 07/04/11 at 12:15 p.m., stated: "Called (physician name) on his cell phone. Rec'd (received) order to send to ER (emergency room ) for eval (evaluation) 911 called. Res (resident) sent via stretcher with 2 attendants noted to have left side weakness and slight facial droop. Remains alert and responsive. 02 NC (nasal cannula) on with 02 sat 92-94. Ambulance personnel failed to take med (medical) records packet (transfer, md orders and d/c summary with them)." - A nursing note, dated 07/04/11 at 17:05 (5:05 p.m.), stated, "This nurse informed (resident's sister's name) that res. was transferred to (name of hospital) for eval (evaluation) at approx (approximately) 12:15 p.m. Res. sister approached this nurse to ask if res. (resident) had gone to ER. This nurse informed her 'yes.' Call placed to (name of hospital) ER. Res. has been admitted to (name of hospital) for [MEDICAL CONDITION] and [MEDICAL CONDITION] ischemia. Sister completely updated on status." On 08/08/11 at approximately 2:00 p.m., the director of nursing (DON - Employee #27A) reviewed the nursing notes in the medical record and reported her belief that the family had received notification of the resident's change in condition. She also felt that the resident's capacity status relieved the facility of any further… | 2014-12-01 |
| 10693 | 10693 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 272 | E | 1 | 1 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, resident interview, family interview, and staff interview, the facility failed to assure ongoing, accurate comprehensive assessments for six (6) of forty-five (45) Stage II sample residents. There was a failure to accurately assess for falls for two (2) residents, a failure to accurately assess for pain for one (1) resident, a failure to accurately assess for toileting needs for one (1) resident, a failure assess bruising for one (1) resident, and a failure to accurately assess the amount of staff assistance needed at meals for three (3) residents. Resident identifiers: #37, #1, #71, #128, #125, #214, and #159. Facility census: 105. Findings include: a) Resident #37 Record review revealed this resident was admitted to the facility on [DATE]. According to an interview with a registered nurse (RN - Employee #86) on 07/26/11 at 9:53 a.m., the resident fell on [DATE] and sustained no injuries. Further medical record review, on 08/02/11, revealed the resident also fell without injuries on 04/19/11, 04/20/11, 07/02/11, 07/06/11, and 07/27/11. Review of the resident's re-admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/04/11, found the assessor indicated, at G0110E and G0110F (relative to locomotion in the room and off the unit), the resident was independent in these areas and needed no staff assistance. This was not accurate, as evidenced by the falls the resident had in his room as well as in another part of the facility on 07/04/11. -- b) Resident #1 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal, making no effort to eat. This was again observed at 8:16 a.m. At 8:35 a.m., her tray was taken away by nursing staff. The resident was not offered assistance prior to removal of her meal. The hallway outside of the resident's room was observed continuously beginning at 8:00 a.m. Facility staff did not enter the res… | 2014-12-01 |
| 10694 | 10694 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 279 | E | 1 | 1 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to develop and/or revise the comprehensive care plans for ten (10) of forty-five (45) Stage II sample residents. The facility failed to assure each care plan was developed by the interdisciplinary team to assure each discipline had correlating goals and interventions for one (1) resident; failed to assure care plans accurately reflected activity of daily living (ADL) needs (specifically need for assistance at meal times) for three (3) residents; failed to develop a care plan for non-pressure related skin conditions (bruising) for one (1) resident; failed to develop a care plan with specific interventions to ensure adequate assessment of a resident with an acute upper respiratory infection; failed to assure a care plan with measurable goals to address pain for one (1) resident; failed to develop a care plan to improve continence for one (1) resident; failed to develop a care plan to adequately address pain for one (1) resident with a [DEVICE]-assisted closure (vac) device who was being treated with psychoactive medications for behaviors that were likely associated with pain; and failed to develop care plan on admission to address two (2) residents who were assessed at that time as having a previous history of falls prior to admission. Resident identifiers: #1, #71, #128, #37, #125, #183, #216, #159, #214, and #206. Facility census: 105 Findings include: a) Resident #37 This resident's care plan relative to nutrition was reviewed on 08/02/11. The care plans reviewed were those in a file at the nurse's station. According to the facility, these were the current care plans. Further review, on 08/03/11, revealed another nutritional care plan dated 06/27/11. This care plan was in the resident's electronic medical record but was not correlated with the hard copy care plan found at the nurses' station, where the current plans were supposed to be found. In other wor… | 2014-12-01 |
| 10695 | 10695 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 280 | E | 1 | 1 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to revise the care plans for six (6) of forty-five (45) Stage II sample residents. These residents' needs and requirements for care changed; however, the care plans were not revised to reflect the changes. When the level of staff assistance with meals changed for four (4) residents, no revisions were made to the care plans to address the increased need. There was also no revision for falls for two (2) residents. Resident identifiers: #71, #128, #1, #101, #206, and #214. Facility census: 105. Findings include: a) Resident #71 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was asleep with her uneaten meal in front of her. At 8:16 a.m., the resident was still asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance. The hallway was observed continuously, beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 a.m., until 8:30 a.m. when the tray was removed from the resident's room. Review of the resident's care plan, dated 07/25/11, revealed the resident required tray set up and "assistance as needed". The Kardex, which is the plan used by nursing assistants, did not correlate with this. The Kardex noted the resident was "independent" with eating meals. Observation revealed the resident required more assistance than was noted in the care plan and Kardex. The care plan had not been revised to reflect the resident's current needs at mealtime. -- b) Resident #128 This resident was observed at breakfast at 8:00 a.m. on 08/02/11; she was just staring at her meal. At 8:16 a.m., the resident was asleep. At 8:30 a.m., her tray was taken away by nursing staff. The resident was not awakened to determine if she needed assistance. The hallway was observed continuously beginning at 8:00 a.m. Facility staff did not enter the resident's room from 8:00 … | 2014-12-01 |
| 10696 | 10696 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 309 | E | 1 | 0 | UBFP12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure (1) of thirteen (13) sampled residents, whose physician gave orders on 10/11/11 for intravenous (IV) antibiotic therapy ([MEDICATION NAME] 1 Gm daily for seven (7) days) to treat a urinary tract infection [MEDICAL CONDITION], received the first dose of [MEDICATION NAME] as scheduled on 10/11/11 due to lack of availability of the medication from the pharmacy. Resident identifier: #16. Facility census: 102. Findings include: a) Resident #16 Medical record review for Resident #16, on 10/25/11, found this [AGE] year old female was admitted to the facility on [DATE] after a four-day hospital stay. The hospital discharge summary revealed the resident had the following Diagnoses: [REDACTED]. The discharge summary also stated: "She was treated with intravenous [MEDICATION NAME]. Urine culture grew proteus mirabilis, sensitive to [MEDICATION NAME]." On 10/25/11 at approximately 1:00 p.m., review of Resident #16's medical record review revealed a physician's orders [REDACTED]." A nursing note dated 10/11/11 at 11:30 a.m. stated, "Resident admitted previous shift to Room (number) under Dr. (name) services. MD in to see Resident today clarification orders obtained as follows: (Symbol for change) [MEDICATION NAME] to 1 grm (gram) IV q (every) 24 hr x 7 days, [MEDICATION NAME] 600 mg PO (by mouth) BID (twice a day) x 10 days r/t (related to) VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) on left heel wound. MD to write order for referral to (name) upon family request. MPOA (medical power of attorney) wants resident to continue wound care with Dr. (name) next appt (appointment) is 10/14/11 @ 3:00 pm. Resp (respirations) even and nonlabored. Abdomen soft and nontender. BS (bowel sounds) (+) (positive) all quads (quadrants). Denies pain @ this time. Will continue to monitor. ABT (antibiotic therapy) ongoing UTI and VRE to left heel wound contact precautions maintained QS … | 2014-12-01 |
| 10697 | 10697 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 323 | G | 1 | 0 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to ensure three (3) of forty-five (45) Stage II sample residents received adequate supervision and assistance devices to prevent avoidable accidents, resulting in actual harm to one (1) resident. Additionally, staff failed to follow the facility's Fall Management Program with respect to documentation, assessment, care planning, and post-fall evaluations. Resident #206 was admitted on [DATE] and sustained five (5) falls between 06/22/11 and 07/18/11; two (2) of the falls required transfer to the hospital, one (1) of which resulted in a fractured clavicle. The resident had diminished cognitive ability due to malignant brain cancer. The interdisciplinary team (IDT) did not develop new interventions that were appropriate for a resident with diminished cognitive ability, relying upon the resident to exercise good judgment to promote her own safety (e.g., instructing the resident to ask for staff assistance with transfers). The facility kept the same interventions in place after the resident continued to sustain falls with serious injuries. Resident #214 sustained a fall on 07/26/11, and staff did not complete a physical assessment of the resident after the fall, nor did they follow the other post-fall action steps outline in the facility's policy. Resident #37 had a care plan intervention for his bed to be in the lowest position due to falls. Observation revealed this intervention was not implemented as planned. Resident identifiers: #206, #214, and #37. Facility census: 105. Findings include: a) Resident #206 1. The medical record for Resident #206, conducted on 08/04/11 at approximately 12:00 p.m., revealed this [AGE] year old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Medical records from Resident #206's hospital stay prior to her admission to the nursing home included a form titled "Determination of Capacity / … | 2014-12-01 |
| 10698 | 10698 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 329 | G | 1 | 0 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, observation, and review interview, the facility failed to ensure the medication regimens for two (2) of forty-five (45) Stage II sample residents were free from unnecessary drugs. One (1) resident (#214) received medications to treat anxiety and [MEDICAL CONDITION] when the resident displayed signs / symptoms of pain, and she was not prescribed any medications to treat pain; this resulted in actual harm (e.g., untreated pain). Another resident (#159) received a medication without adequate indications for its use. Resident identifiers: #159 and #214. Facility census: 105. Findings include: a) Resident #214 1. Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or if she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident . A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (VAC) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. In Section 13.1a (integumentary / feet) of the admission nursing assessment, the assessor failed to mark a response to the following question: "Is there pain associated with the wound/skin condition?" - This section of the assessment was left blank. In Section 14.0 of the nursing admission assessment, the assessor responded as follows: - "At anytime during the last five (5) days has the resident: Been on a scheduled pain medication regimen?" = No - "Been on a PRN (as needed) pain medication?" = No - "Had pain … | 2014-12-01 |
| 10699 | 10699 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 425 | E | 1 | 0 | UBFP12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure an intravenous (IV) antibiotic was available for administration as ordered for (1) of thirteen (13) sampled residents (#16), whose physician gave orders on 10/11/11 for IV Rocephin 1 Gm daily for seven (7) days to treat a urinary tract infection (UTI). Additionally, staff failed to obtain from the facility's emergency drug box and administer a dose of Lovenox to Resident #59 when that medication was not available from the pharmacy. Resident identifiers: #16 and #59. Facility census: 102. Findings include: a) Resident #16 Medical record review for Resident #16, on 10/25/11, found this [AGE] year old female was admitted to the facility on [DATE] after a four-day hospital stay. The hospital discharge summary revealed the resident had the following Diagnoses: [REDACTED]. The discharge summary also stated: "She was treated with intravenous Rocephin. Urine culture grew proteus mirabilis, sensitive to Rocephin." On 10/25/11 at approximately 1:00 p.m., review of Resident #16's medical record review revealed a physician's orders [REDACTED]." A nursing note dated 10/11/11 at 11:30 a.m. stated, "Resident admitted previous shift to Room (number) under Dr. (name) services. MD in to see Resident today clarification orders obtained as follows: (Symbol for change) Rocephin to 1 grm (gram) IV q (every) 24 hr x 7 days, Zyvox 600 mg PO (by mouth) BID (twice a day) x 10 days r/t (related to) VRE (Vancomycin-resistant Enterococcus) on left heel wound. MD to write order for referral to (name) upon family request. MPOA (medical power of attorney) wants resident to continue wound care with Dr. (name) next appt (appointment) is 10/14/11 @ 3:00 pm. Resp (respirations) even and nonlabored. Abdomen soft and nontender. BS (bowel sounds) (+) (positive) all quads (quadrants). Denies pain @ this time. Will continue to monitor. ABT (antibiotic therapy) ongoing UTI and VRE to left heel wound c… | 2014-12-01 |
| 10700 | 10700 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 428 | D | 1 | 0 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the pharmacist identified and reported irregularities found in the medication regimen of one (1) of forty-five (45) Stage II sample residents. One (1) resident had a drug prescribed without a supporting diagnosis, and this was not identified by the consultant pharmacist. Resident identifier: #159. Facility census: 105. Findings include: a) Resident #159 On 08/09/11 at approximately 10:25 a.m., medical record review for Resident #159 revealed she received the medication Mirapex 1 mg po (by mouth) twice a day everyday for Parkinson's disease since 08/18/10. Further medical record review found the resident did not have an active [DIAGNOSES REDACTED]. Interviews with Employee #27A (the director of nursing - DON) and Employee #28A (a registered nurse consultant) revealed no supporting [DIAGNOSES REDACTED]. Review of the resident's most recent medication regimen review by the consultant pharmacist, dated 07/13/11, found no irregularities were identified. . | 2014-12-01 |
| 10701 | 10701 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 278 | D | 1 | 0 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to assure the minimum data set assessment (MDS) contained accurate information for one (1) of forty-five (45) Stage II sample residents with respect to the number of falls that the resident had experienced since she was admitted to the facility. Resident identifier: #214. Facility census: 105. Findings include: a) Resident #214 Record review revealed this resident was admitted on [DATE]. Review of the medical record found Resident #214 had fallen on 07/23/11. Observation, on 07/26/11, found this resident had fallen from her bed to the floor, and a licensed practical nurse (LPN - Employee #13) was there with her waiting until someone could help get the resident out of the floor. Review of her Medicare 5-Day MDS, with an assessment reference date (ARD) of 07/26/11, found Section J was encoded to indicate the resident had experienced a fall in the last month prior to admission. In response to a question about whether the resident had any falls since admission or the prior assessment (whichever was more recent), the assessor encoded "yes" and noted the resident had one (1) fall with no injury. This was not correct, since the assessment reference period for this assessment would include events that occurred on 07/26/11. . | 2014-12-01 |
| 10702 | 10702 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 246 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide reasonable accommodations to one (1) randomly observed resident and two (2) of twenty-one (21) sampled residents. Resident #72's bed did not accommodate the resident's height. Resident #4's neck collar did not allow the resident to eat without difficulty, and he was not consistently provided with adaptive eating utensils to facilitate self-feeding. Resident #137 did not have an appropriately sized wheelchair. Resident identifiers: #72, #4, and #137. Facility census: 138. Findings include: a) Resident #72 Observation, on 08/19/09 at 10:00 a.m., found the resident's feet dangled over the end of the bed. The resident's feet were also in a downward position. An interview with a licensed practical nurse (LPN - Employee #106), on 08/19/09 at 10:10 a.m., revealed the resident was tall and needed to pulled up in bed. The bed was observed to have 2 inches of head room at the top of the bed. If staff positioned the resident by pulling the resident up in bed, this would not alleviate the problem of the resident's dangling feet. Medical record review disclosed the resident's height was 68 inches, and he had a [DIAGNOSES REDACTED]. The resident had foot drop, which required his feet to be elevated and positioned to prevent further problems. b) Resident #4 A random observation, on 08/17/09 at 1:00 p.m., found Resident #4 sitting in a wheelchair wearing a hard cervical collar on his neck. A meal tray was on the overbed table, and because of the rigid collar, Resident #4 had difficulty finding his food and using his eating utensils. No staff was observed to be assisting the resident with his meal. On 08/17/09 at 2:30 p.m., medical record review noted that, on 08/13/09, the resident was sent from another rehabilitation hospital with a suggestion to use red handled utensils for eating, which had been supplied by the transferring facility. The medical record also contained … | 2014-12-01 |
| 10703 | 10703 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 329 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility did not ensure the drug regimens of two (2) of twenty-one (21) sampled residents were free of unnecessary drugs. Resident #76, who had a [DIAGNOSES REDACTED]. Resident #13 was receiving a pain medication in an amount over the recommended dose which was also ineffective in controlling the resident's pain. Facility census: 138. Findings include: a) Resident #76 review of the resident's medical record revealed [REDACTED]. On 07/01/09, the physician ordered an antipsychotic medication of [MEDICATION NAME] 50 mg at bedtime. On 07/22/09, a physician ordered [MEDICATION NAME] 1 mg IM every six (6) hours PRN for forty-eight (48) hours. On 07/30/09, a physician ordered [MEDICATION NAME] 1 mg IM now then may repeat every two (2) hours PRN until calm for forty-eight (48) hours. A nursing note, dated 06/30/09 at 5:30 p.m., indicated, "Resident crying and screaming she does not want to be here. She is kicking and swinging at the other resident and staff. She does not want anyone in the hallway. Shoves residents out of her way. Physician notified and gave an order for [REDACTED]. A nursing note, dated 07/01/09 at 3:00 a.m., indicated, "Agitated, slapping and hitting staff at this time. Physician called [MEDICATION NAME] 1 mg IM every 3 hours as needed for 24 hours." A nursing note, dated 07/21/09 at 8:00 a.m., indicated, "Resident observed sitting on floor in hall outside of her room." At 12:00 p.m., "Resident found kneeling at bedside. Physician notified of fall." On 07/30/09, the physician was notified of behaviors of crying and kicking at staff and ordered [MEDICATION NAME]. A "Psychiatric Med Check Follow-up" (dated 07/01/09) indicated, "The resident has received [MEDICATION NAME] which just made her more restless. We increased the dose of [MEDICATION NAME], however she continued to deteriorate not respond. Klonopin was added and she received [MEDICATION NAME] which has made her m… | 2014-12-01 |
| 10704 | 10704 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 514 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records for each residents that were complete and/or accurate, as evidenced by an incomplete discharge summary, the medical information of one (1) resident misfiled on the wrong chart, and the Medication Administration Record [REDACTED]. This was evident in the medical records of three (3) of twenty-four (24) sampled residents. Resident identifiers: #141, #33, and #25. Facility census: 138. Findings include: a) Resident #141 Review of Resident #141's discharge summary revealed numerous components had not been completed. The discharge summary contained places to record the date of discharge, time and location of discharge; the name of facility / agency to which released; written discharge instructions were given and to whom; the date of the summary by the nurse who wrote it; the prognosis and the rehabilitation potential as written by the physician; and the provisional and final [DIAGNOSES REDACTED]. All of the aforementioned areas were blank. Additionally, the physician signed and dated this form on 08/06/09. However, the resident was not discharged until 08/13/09. Interview with the administrator, on 08/20/09 at 8:30 a.m., revealed this was the resident's final discharge summary for the physician to complete. She acknowledged it was not fully completed by the physician. b) Resident #33 Review of Resident #33's medical record, at 3:50 p.m. on 08/18/09, disclosed the physician's progress notes for another resident (#37) on his chart. The charge nurse of the unit was informed and removed Resident #37's records from Resident #33's chart. c) Resident #25 Medical record review, on 08/19/09, revealed the MAR for 08/08/09 had several blank areas. The column for initialing having administered the 8:00 a.m. dose of [MEDICATION NAME] was left blank; however, an audit of the number of medication doses on hand indicated the 8:00 a.m. doses had been given. Employee #95 (t… | 2014-12-01 |
| 10705 | 10705 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 225 | E | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review and staff interview, the facility failed to verify the status of employees on the State nurse aide registry concerning findings of abuse, neglect, mistreatment of [REDACTED]. This was evident for four (4) of five (5) sampled employees who had worked with the facility for greater than one (1) year, and for four (4) of five (5) sampled employees who have been recently hired. Staff identifiers: #1, #22, #33, #97, #125, #130, #150, and #155. Facility census: 138. Findings include: a) Employees #125, #33, #22, #155, #1, #97, #130, and #150 The personnel files of Employees #125, #33, #22, and #155, all of whom were recent hires by the facility, contained no evidence of verification with the WV Nurse Aide Abuse Registry in order to ensure there were no findings against them for abuse, neglect, mistreatment of [REDACTED]. The personnel files of Employees #1, #97, #130, and #150, all of whom worked at the facility for greater than one (1) year, also contained no evidence of verification with the Nurse Aide Abuse Registry. On 08/18/09 at approximately 2:30 p.m., the human resource director (Employee #8) and the administrator stated the facility checked the WV Nurse Aide Abuse Registry only for persons employed as nursing assistants, but not for licensed practical nurses, registered nurses, dietary employees, housekeeping employees, maintenance employees, etc., any of whom may have had previous employment as a nursing assistant with a finding of abuse, neglect, etc. On 08/19/09 at approximately 1:00 p.m., the assistant director of nursing (Employee #139) had no further information to provide, when informed of the above findings regarding the facility not having had all employees verified with the WV Nurse Aide Abuse Registry. --- Part II -- Based on record review and staff interview, the facility failed to obtain the required statewide criminal background check on every employee in an effort to uncover past criminal conv… | 2014-12-01 |
| 10706 | 10706 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 157 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed, for one (1) of twenty-one (21) sampled residents, to ensure a resident's oncologist was notified when both pain and nausea medications were not effective. Resident identifier: #13. Facility census: 138. Findings include: a) Resident #13 1. During an initial tour of the facility on 08/17/09 at 1:00 p.m., observation found Resident #13 lying in bed with facial grimacing and guarding. A meal tray was observed on the bed side table set up, but the food was not touched. When interviewed at this time, Resident #13 reported, "I am so sick at my stomach." When asked if she had pain, she reported having intermittent stomach pain and pain in her breast, pointing to her right breast. When asked if they were giving her medications, she said yes but reported the pain and nausea medications were not working. On 08/17/09 at 2:00 p.m., medical record review revealed Resident #13 had been diagnosed with [REDACTED]. In July 2009, she was admitted to the hospital and had surgery on her breast, for which a drain was placed. The medical record also noted she had a abscess of the breast, and the [MEDICAL CONDITION] treatments had left [MEDICAL CONDITION] her breast abdomen and back. The orders for [MEDICAL CONDITION] and [MEDICAL CONDITION] were placed on hold. She returned to the facility on [DATE] and, since then, the [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments have remained on hold. The medical record indicated that, on 07/30/09, her family physician (not her oncologist) was notified the medication [MEDICATION NAME] was not effective in relieving her pain. On 07/30/09, an order was received to increase the frequency of the [MEDICATION NAME] from every six (6) hours to every four (4) hours for pain. On 08/14/09, her family physician (not her oncologist) was notified the medication [MEDICATION NAME] was not effective in relieving her nausea, and h… | 2014-12-01 |
| 10707 | 10707 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 281 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, one (1) of twenty-one (21) sampled residents, to ensure a medication was properly administered. A nurse administered via gastrotomy tube a medication that was not recommended to be crushed. Resident identifier: #25. Facility census: 138. Findings include: a) Resident #25 Medication observation, completed on the morning of 08/19/09, found on Resident #25's Medication Administration Record [REDACTED]. However, the order on the MAR failed to indicate this medication was sustained release. Review of the actual medication contained in the cart found it was [MEDICATION NAME] SR (sustained release). At 9:00 a.m., the dispensing pharmacy was called, and the pharmacist (Employee #154), when interviewed, identified that the medication supplied to Resident #25 was extended release and should not be crushed for administration via the gastrotomy tube. Subsequent review of the MAR indicated [REDACTED]. According to http://www.rxlist.com/[MEDICATION NAME]-sr-drug.htm: "It is particularly important to administer [MEDICATION NAME] SR Tablets in a manner most likely to minimize the risk of [MEDICAL CONDITION] (see Warnings). Gradual escalation in dosage is also important if agitation, motor restlessness, and [MEDICAL CONDITION], often seen during the initial days of treatment, are to be minimized. If necessary, these effects may be managed by temporary reduction of dose or the short-term administration of an intermediate to long-acting sedative hypnotic. A sedative hypnotic usually is not required beyond the first week of treatment. [MEDICAL CONDITION] may also be minimized by avoiding bedtime doses. If distressing, untoward effects supervene, dose escalation should be stopped. [MEDICATION NAME] SR should be swallowed whole and not crushed, divided, or chewed. . | 2014-12-01 |
| 10708 | 10708 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 309 | G | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed, for one (1) of twenty-one (21) sampled residents, to ensure that care and services were provided for a resident who was experiencing unrelieved pain and nausea. This caused physical and emotional harm to Resident #13. Resident identifier: #13. Facility census: 138. Findings include: a) Resident #13 1. During an initial tour of the facility on 08/17/09 at 1:00 p.m., observation found Resident #13 lying in bed with facial grimacing and guarding. A meal tray was observed on the bed side table set up, but the food was not touched. When interviewed at this time, Resident #13 reported, "I am so sick at my stomach." When was asked if she had pain, and she reported having intermittent stomach pain and pain in her breast, pointing to her right breast. When asked if they were giving her medications, she said yes but reported the pain and nausea medications were not working. On 08/17/09 at 2:00 p.m., medical record review revealed Resident #13 had been diagnosed with [REDACTED]. In July 2009, she was admitted to the hospital and had surgery on her breast, for which a drain was placed. The medical record also noted she had an abscess of the breast, and the [MEDICAL CONDITION] treatments had left [MEDICAL CONDITION] her breast, abdomen and back. The orders for [MEDICAL CONDITION] and [MEDICAL CONDITION] were placed on hold. She returned to the facility on [DATE] and, since then, the [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments have remained on hold. The medical record indicated that, on 07/30/09, the attending physician was notified the medication [MEDICATION NAME] was not effective in relieving the resident ' s pain. On 07/30/09, an order was received to increase the frequency of the [MEDICATION NAME] from every six (6) hours to every four (4) hours for pain. On 08/14/09, her attending physician was notified the medication [MEDICATION NAME… | 2014-12-01 |
| 10709 | 10709 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 406 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, it was determined that the facility failed to assure that the rehabilitation services department provided effective interventions in a timely manner to promote independence in eating for one (1) of twenty-one (21) sampled residents with known difficulties in self-feeding. Resident identifier: #4. Facility census: 138. Findings include: a) Resident #4 A random observation, on 08/17/09 at 1:00 p.m., found Resident #4 sitting in a wheelchair wearing a hard cervical collar on his neck. A meal tray was on the overbed table, and because of the rigid collar, Resident #4 had difficulty finding his food and using his eating utensils. No staff members were observed to be assisting the resident with his meal. On 08/17/09 at 2:30 p.m., medical record review noted that, on 08/13/09, the resident was admitted to the facility from a rehabilitation hospital with a suggestion to use red handled utensils for eating, which had been supplied by the transferring facility. The medical record also contained an order for [REDACTED]. On 08/18/09, during observations of meal tray preparation, red handled built-up utensils were noted to be available in the kitchen but not supplied to the resident. At this meal, the resident was observed to be in a geri chair and struggling to see his food. Once supplied with the red handled utensils, he grasped the spoon easier with enhanced manual dexterity, but the visual field remained an issue. During an interview on the afternoon of 08/18/09, the occupational therapist (Employee #153) stated the facility was still in the process of evaluating the resident to determine which adaptive equipment would be best; Employee #153 acknowledged that Resident #4's main problem with self-feeding was not having a clear visual field. There was no evidence that the rehabilitative department developed and implemented interventions to address the resident ' s inability to self-feed d… | 2014-12-01 |
| 10710 | 10710 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 425 | F | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy, the facility failed to provide pharmaceutical services to meet the needs of each resident and failed to ensure the in-house pharmacy and the consultant pharmacist put in place systems, in accordance with State law, to ensure each resident received medications in the appropriate form and/or irregularities were promptly identified and mitigated. This deficient practice affected one (1) of twenty-one (21) sampled residents and had the potential to affect all residents receiving pharmaceutical services from the facility. Resident identifier #25. Facility census: 138. Findings include: a) Resident #25 Observation, during medication administration on the morning of 08/19/09, revealed the in-house pharmacy sent two (2) medications for Resident #25 (who received his medications via gastrostomy tube) that were not to be open and crushed (Wellbutrin SR and Avocat). A telephone interview with the pharmacist (Employee #154), on 08/19/09 at 9:00 a.m., verified Wellbutrin SR should not be crushed and placed down a gastrotomy tube. An audit of the medication drawer in conjunction with Resident #25's Medication Administration Record [REDACTED]. This review revealed the in-house pharmacy and the consultant pharmacist did not have a system in place to ensure appropriate medications were given and to promptly identify possible irregularities. On 08/19/09 at 10:00 a.m., a review of the facility's policy and procedure manual for pharmaceutical services including the duties of the consultant pharmacist, titled Organizational Aspects IA1-1 (effective date 08/01/08) revealed the following expectations of the consultant pharmacist: - Performing and initial medication use assessment for each new resident - Maintaining a medication profile on each resident that includes all medications dispensed and facility -provided information such as resident's age, diagnosis, condition, medication allergies [RED… | 2014-12-01 |
| 10711 | 10711 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 152 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the determination of incapacity, for one (1) of twenty-one (21) sampled residents, was documented in accordance with State law. Resident #106's record lacked any information regarding the cause or nature of the incapacity as required by W.Va. Code 16-30-7(b). Additionally, there was no evidence the resident was notified of the determination of incapacity as required by W.Va. Code 16-30-7(c). Resident identifier: #106. Facility census: 138. Findings include: a) Resident #106 According to the medical record, the resident was admitted to the facility on [DATE]. A "Physician's Determination of Capacity" form, completed by the attending physician on 04/23/08, indicated the resident "Demonstrates INCAPACITY to make medical decisions" for a "Short term" duration. The form listed "sequelae of [MEDICATION NAME] toxicity" without additional explanation as to the nature or cause of the resident's incapacity. Additionally, no evidence could be found the physician informed this conscious resident of the determination of incapacity or of the fact that a surrogate decision-maker would be acting on the resident's behalf. During an interview with the administrator and the three (3) social workers at 2:40 p.m. on 08/19/09, they acknowledged, after reviewing the resident's determination of incapacity, the documentation was incomplete. b) Per W.Va. Code 16-30-7. Determination of incapacity. "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical… | 2014-12-01 |
| 10712 | 10712 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 159 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review and staff interview, the facility failed to obtain written authorization from the legal representative for financial decisions for one (1) of twenty-one (21) sampled residents and one (1) resident of random opportunity, both of whom had been determined to lack the capacity to understand and make medical decisions and whose personal funds were held and managed by the facility. Resident identifiers: #106 and #5. Facility census: 138. Findings include: a) Resident #106 According to the medical record, Resident #106 was admitted to the facility on [DATE], and was determined to lack the capacity to understand and make medical decisions on 04/23/08. He signed his own admission information, which did not include an authorization for handling of personal funds. The resident had a durable power of attorney (DPOA), but there was no evidence the DPOA signed an authorization for the facility to handle the resident's personal funds. During an interview with the person responsible for handling resident funds at 10:00 a.m. on 08/19/09, she acknowledged there was no written authorization on file but stated that new forms had been developed and signatures had been obtained after the previous resurvey. She would look for them. At 08:30 a.m. on 08/20/09, the administrator presented the mislaid authorization form signed by the resident, but the date of the authorization was September 2008, which was after the resident had been determined to be incapacitated. b) Resident #5 Medical and financial records of Resident #5 revealed she had been determined to lack the capacity to make health care decisions, and her son had been named her health care surrogate (HCS). The HCS, who was not the legal power of attorney for financial decision-making, was permitted to sign the form authorizing the facility to deposit and handle the resident's personal funds, which included a pension not associated with the social security program. During an in… | 2014-12-01 |
| 10713 | 10713 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 250 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to re-evaluate a resident's determination of incapacity to make informed decisions about health care after a determination made shortly after admission to the facility, in 2008, indicated the resident's incapacity was of a short-term duration. This affected one (1) of twenty-one (21) sampled residents. Resident identifier: #106. Facility census: 138. Findings include: a) Resident #106 Clinical record review disclosed Resident #106 was a [AGE] year-old male admitted on [DATE], with [DIAGNOSES REDACTED]. On 04/23/08, the resident was determined to lack capacity to make medical decisions by his physician for a short-term duration without a stated cause other than the [DIAGNOSES REDACTED]. There was no reassessment of the resident's capacity, although a determination of capacity form was in the record and signed by the physician on 09/03/09. During an interview at 11:00 a.m. on 08/05/09, the social worker stated that, usually, short-term determinations of capacity were re-assessed after three (3) months, and this one had just been overlooked. . | 2014-12-01 |
| 10714 | 10714 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 272 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of the minimum data set assessment (MDS) for one (1) of twenty-one (21) residents on the sample whose ability to verbally communicate with others was impaired. Resident identifier: #25. Facility census: 138. Findings include: a) Resident #25 According to the medical record, Resident #25 was an [AGE] year-old male admitted on [DATE], following hospitalization for injuries sustained in a fall at home. Prior to his fall, he lived with his spouse at home and was self-sufficient. Admission [DIAGNOSES REDACTED]. Medical record review also disclosed the resident was admitted with severe dysphagia, making a PEG tube necessary for nutrition because of an inability to swallow and the need for intermittent suctioning to clear oral secretions. The resident wore a Miami J neck collar when sitting up. On 07/18/09, a nurse noted the resident could verbally communicate by "...whispers but you can understand." On 07/22/09, a nursing note documented, "....you have to listen to him closely." The information in the nursing notes was verified with the assistant director of nurses (ADON) during an interview at 3:15 p.m. on 08/18/09. The admission MDS of 07/24/09 and the 14-day MDS of 07/29/09 indicated, at Items C4 and C5, that the resident had "clear speech" and was always "understood" by others. During an interview with the MDS coordinator and the director of nurses (DON) at 3:45 p.m. on 08/19/09, concerns related to the resident's ability to verbally communicate to others were discussed with the result that they would review the chart and return the following morning. On the morning of 08/20/09, the DON and ADON acknowledged the resident had communication problems that were not accurately reflected on the MDS assessments. . | 2014-12-01 |
| 10715 | 10715 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 279 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan with measurable goals and nursing interventions to address all identified problems for one (1) of twenty-one (21) sampled residents. Resident identifier: #25. Facility census: 138. Findings include: a) Resident #25 According to the medical record, Resident #25 was an [AGE] year-old male admitted on [DATE], following hospitalization for injuries sustained in a fall at home. Prior to his fall, he lived with his spouse at home and was self-sufficient. Admission [DIAGNOSES REDACTED]. Medical record review also disclosed the resident was admitted with severe dysphagia, making a PEG tube necessary for nutrition because of an inability to swallow and the need for intermittent suctioning to clear oral secretions. The resident wore a Miami J neck collar when sitting up. On 07/18/09, a nurse noted the resident could verbally communicate by "...whispers but you can understand." On 07/22/09, a nursing note documented, "....you have to listen to him closely." The information in the nursing notes was verified with the assistant director of nurses (ADON) during an interview at 3:15 p.m. on 08/18/09. The communication needs of this resident are not addressed in his care plan and the necessary interventions are not being communicated through the care plan to all care givers. The physician determined, on 07/27/09, the resident lacked the capacity to make informed health care decisions, and his medical power of attorney representative (MPOA) was making health care decisions on his behalf (as evidenced by her signature in the record), but no care plan was developed to address his change in cognitive status. During an interview with the MDS coordinator and the director of nurses (DON) at 3:45 p.m. on 08/19/09, concerns related to the resident's ability to verbally communicate to others were discussed with the result that they would review the chart and return the following morn… | 2014-12-01 |
| 10716 | 10716 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 285 | B | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the mental health needs of a new resident were evaluated prior to admission through the State-mandated pre-admission screening tool, the form PAS-2000. This was evident for two (2) of twenty-four (24) residents on the sample. Resident identifiers: #33 and #140. Facility census: 138. Findings include: a) Resident #33 Clinical record review disclosed the resident was admitted on [DATE], but the determination as to whether a Level II evaluation was required was not made until 03/17/09, as indicated by the dated signature in Section V of the form PAS-2000. b) Resident #140 Clinical record review disclosed the resident was admitted on [DATE], but the determination as to whether a Level II evaluation was required was not made until 07/08/09, as indicated by the dated signature in Section V of the form PAS-2000. c) In an interview at 2:40 p.m. on 08/19/09, the facility's three (3) social workers acknowledged the Level II determinations occurred after admission for both residents. . | 2014-12-01 |
| 10717 | 10717 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2011-08-22 | 278 | D | 1 | 0 | 08RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the accuracy of a weight recorded in the minimum data set assessment for one (1) of six (6) sampled residents. Resident identifier: #184. Facility census: 180. Findings include: a) Resident #184 Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE] and was readmitted to the facility following a hospital stay on 05/23/11, weighed 87 pounds (#) on 05/25/11; this was recorded on sheet containing nothing but weights found in the medical record. Review of this resident's initial minimum data set assessment (MDS), with an assessment reference date of 05/29/11, found the assessor recorded the resident's weight as being 132# during this assessment reference period. During an interview on 08/17/11 at 3:30 p.m., the dietary manager (Employee #63) verified that she completed this section on this MDS. She stated she knew this weight of 185# was not accurate, because this resident never weighed 132#. She stated this must have been a data entry error, because she kept a close eye on this resident's weight and the resident never weighed that much. . | 2014-12-01 |
| 10718 | 10718 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2011-08-22 | 279 | D | 1 | 0 | 08RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to develop a comprehensive care plan based on the results of a comprehensive assessment for one (1) of six (6) sampled residents. Resident #185's assessment identified his weight as 129 pounds (#). His care plan contained a goal for him to maintain his weight between 175# and 195#. This care plan was not based his assessment information. Resident identifier: #185. Facility census: 180. Findings include: a) Resident #185 Medical record review revealed this [AGE] year old male was admitted to the facility on [DATE]. According to his nursing admission assessment dated [DATE], he weighed 130 pounds (#) on admission. According to his weight record, subsequent weights were as follows: 129.2# on 05/31/11; 128# on 06/03/11; and 126.2# on 07/03/11. Further review of the medical record found a Medicare 14-Day minimum data set assessment (MDS) with an assessment reference date of 06/01/11, which stated, in Section K0200, that this resident's weight was 129#. The assessor indicated the resident had not experienced a significant weight loss of five percent (5%) in the last month or ten percent (10%) in the last six (6) months. The assessor further indicated that the received received fifty-one percent (51%) or greater of his total daily calories through his feeding tube. Review of a hospital record titled "Outside Facility Transfer Form" dated 05/19/11, the resident's weight was 185#. In another hospital record (a progress note by the hospital's dietician dated 05/19/11 at 9:11 a.m.), the resident's weight was 139.7#. The nursing home's consultant dietician completed a medical nutritional therapy review on the resident on 05/25/11. This assessment stated the resident's weight was 185# at that time. Subsequently, his initial comprehensive care plan, which was based on a weight of 185#, contained a goal for him to maintain his weight between 175# and 195#. The director of nursing (DON), when … | 2014-12-01 |
| 10719 | 10719 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2011-08-22 | 514 | D | 1 | 0 | 08RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the clinical record contained complete and accurate information about a resident's skin condition for one (1) of six (6) sampled residents (#184). On admission, Resident #184 had a Stage 3 pressure ulcer, which later declined to a Stage 4, and for which she received daily treatments. "Nursing Daily Skilled Summary" forms, used by the facility to record assessment information about various body systems, contained check boxes to prompt nurses to record specific information - such as the presence of pressure ulcers. Ten (10) such summary forms, entered in the resident's record between 06/07/11 and 06/24/11, were either left blank or were specifically - and incorrectly - marked "No problems". Additionally, although assessments of her wound were being recorded on a pressure ulcer log used to track the wounds of multiple residents simultaneously, Resident #184's own medical record did not contain a weekly description of the characteristics of her wound as it was being assessed between the dates of 07/05/11 and her date of discharge on 07/13/11. Resident identifier: #184. Facility census: #180. Findings include: a) Resident #184 1. Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE], was readmitted to the facility following a hospital stay on 05/23/11. Assessment information revealed the presence of a Stage 3 pressure ulcer on the resident's coccyx upon her return from the hospital. Review of her physician's telephone orders found an order, dated 05/25/11 at 12:30 p.m., stating (quoted as written): "(1) Cleanse wound to Coccyx /c (with) [MEDICATION NAME], pat dry, apply Santyl. Cover /c 4x4 [MEDICATION NAME]. (Symbols for "change every day') and PRN (as needed) until resolved. @ (At) drsg (dressing) (symbol for 'change') complete daily pressure ulcer monitoring record. (2) Ensure drsg is C/D/I (clean / dry / intact) Q (eve… | 2014-12-01 |
| 10720 | 10720 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2011-08-22 | 280 | D | 1 | 0 | 08RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to review and revise the care plan a resident was no longer receiving a gastrostomy tube ([DEVICE]) feeding. The care plan did not reflect the resident's current health status and care needs for one (1) of six (6) sampled residents. Resident identifier: #184. Facility census: 180. Findings include: a) Resident #184 Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE], was readmitted to the facility following a hospital stay on 05/23/11. Her care plan, dated 05/30/2011, stated she "receives enteral nutrition related to impaired swallowing, failure to eat, anorexia, burning mouth syndrome and nausea and vomiting." Her goal stated she would have nutrition and hydration needs met and maintained with enteral feedings as ordered and stable weights between 87 pounds (#) and 110#. The approaches were focused on the [DEVICE] feeding and monitoring her tolerance of the feeding. Resident #184 was transferred to the hospital on [DATE]; she was having some complications with her [DEVICE], and this was the second time she had been transferred to the hospital since her admission due to her [DEVICE] coming out. She was receiving speech therapy at that time and had been receiving some foods by mouth. When she returned from the hospital on [DATE], she was no longer receiving feedings by [DEVICE] but had an order for [REDACTED]. The care plan, upon her return from the hospital on [DATE], continued to identify this resident as receiving enteral nutrition. It was not updated to reflect that she was receiving food by mouth as her primary source of nutrition. The dietary manager (Employee #63), when interviewed at 3:30 p.m. on 08/17/11, verified that the care plan should have been updated when the resident returned from the hospital to reflect her current status, because she was receiving a regular diet at that time. Employee #63 verified that she w… | 2014-12-01 |
| 10721 | 10721 | FAIRHAVEN REST HOME INC | 515021 | 700 MADISON AVENUE, PO BOX 2806 | HUNTINGTON | WV | 25727 | 2011-08-19 | 441 | F | 1 | 0 | FPYI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of infection control documentation, medical record review, staff interview, review of West Virginia Bureau for Public Health Guidelines for Scabies Outbreaks in Institutions, Health Care Facilities, Prisons, Dormitories, Shelters (published August 2010), review of facility policy related to scabies, and interview with a representative of the county health department, the facility failed to establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. The facility failed to appropriately investigate, control, and prevent the spread of a scabies infection in the facility. The facility provided treatment for [REDACTED]. The facility failed to screen residents for signs and symptoms of scabies infection in accordance with physician orders. The facility failed to notify the local health department concerning the outbreak of scabies in their facility in accordance with the West Virginia Bureau for Public Health Guidelines. When the local health department contacted the facility based upon an anonymous report, the facility provided inaccurate information related to the scabies outbreak in their facility. This deficient practice affected six (6) of forty-one (41) residents and eleven (11) of seventy-three (73) employees. Resident identifiers: #42, #13, #15, #27, #14, and #32. Employee identifiers: #51, #23, #31, #33, #43, #44, #51, #46, #15, #22, and #37. Facility census: 41. Findings include: Findings include: a) The acting interim administrator (Employee #9) provided evidence that Employee #51 (in housekeeping) received treatment for [REDACTED]. Review of the medical record found Resident #42 was admitted to an acute care facility for an acute change of condition on 07/22/11. She returned to the facility on [DATE], with a discharge summary documenting the resident presented with itching and received treatment for [REDACTED]. She was discharged back to the ho… | 2014-12-01 |
| 10722 | 10722 | GLEN WOOD PARK, INC. | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-08-24 | 329 | D | 1 | 0 | HTIL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assess one (1) of six (6) sampled residents for possible underlying causes of the resident's behavior prior to administering a psychoactive medication ([MEDICATION NAME]). Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Review of the nurses' notes from [DATE] through [DATE] revealed the following entries (quoted as written): - On [DATE] at 3:55 p.m.: "Vitals were taken temperature 97.3, pulse 107, Respirations 26, blood pressure ,[DATE]." - On [DATE] at 8:00 p.m.: "she took her medications without problems no distress was noted. The resident was taking off her oxygen and the nurse instructed her to leave it on. Her oxygen saturation was 93%." - On [DATE] at 8:30 p.m.: "Resident in bed call light in reach. Took meds with no problems or distress. Taking oxygen off face. Instructed to leave on face. Resident stated, 'I don't want that on my face.' oxygen saturation was 93%. Lung sounds clear. Will continue to monitor." - On [DATE] at 10:00 p.m.: "Resident hollering to be turned. Staff goes in to turn resident when leaving she wants to be turned again. Continues to remove oxygen. Vitals 97.3, 107, 26, ,[DATE]." - On [DATE] at 12:00 a.m.: "Resting in bed - call light within reach. Yelling out to be turned - before nursing assistant can leave room pt in yelling again. Pt. yelling, 'God Help me.' When ask if she was hurting pt. states, 'no' VS (vital signs) WNL (within normal limits). oxygen saturation 94% Lungs clear. oxygen in use as ordered. - cont to remove oxygen tubing from nostril." - On [DATE] at 1:20 a.m.: "cont to yell out and move around in bed - [MEDICATION NAME] given per prn order. cont. to remove oxygen from nostrils - lungs clear. nursing assistant sitting at bedside to give comfort to pt." - On [DATE] at 2:00 a.m.: "remains in bed. quiet at present. Requires assist with ADL's, foley patent and draining dark yellow urine." - On [DATE… | 2014-12-01 |
| 10723 | 10723 | GLEN WOOD PARK, INC. | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-08-24 | 157 | D | 1 | 0 | HTIL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and record review the facility failed to immediately notify the physician of one (1) of six (6) sampled resident's death. Resident #60 was a full code. She was found by nursing staff with no pulse and no respirations on [DATE]. Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Resident #60 had elected to be a full code. Review of the nurses' notes for [DATE] revealed the following entries (quoted as written): - On [DATE] at 4:40 a.m.: "nursing assistants entered resident's room and found resident unresponsive and came to get nurses. Upon examining resident - 0 pulse or heartbeat noted no breathe sounds notes. Tongue hanging out of mouth - head turned to L side Body cold and stiff. Resident obviously expired." - On [DATE] at 4:41 a.m.: "Family was notified of death." - On [DATE] at 4:42 a.m.: "Funeral Home was notified of death." - On [DATE] at 4:44 a.m.: "Senior vice president was notified of death." - On [DATE] at 4:45 a.m.: "Vice president of resident services was notified of death." - On [DATE] at 5:00 a.m.: "RN on call was notified of death." Review of the nursing notes found no evidence that the physician was notified. - On [DATE], interviews were conducted with the following employees: - Employee #52 (certified nursing assistant), when interviewed at 1:30 p.m., stated he had entered the room at 4:40 a.m. to reposition the roommate of Resident #60. At this time, he noticed Resident #60 was turned sideways and "... her tongue was drooped and purplish colored." He stated he told Employee #73 (certified nursing assistant), "She looks like she passed away." He left the room to tell the nurse (Employee #64). - Employee #73, when interviewed at 2:30 p.m., verified she and Employee #52 found Resident #60 around 4:00 a.m. She stated, "She felt cold and her tongue was hanging out of her mouth." - Employee #64 (licensed practical nurse) was interviewed at 10:30 a.m. When asked if she knew t… | 2014-12-01 |
| 10724 | 10724 | GLEN WOOD PARK, INC. | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-08-24 | 281 | D | 1 | 0 | HTIL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide care to one (1) of (6) sampled residents in accordance with the physician's orders [REDACTED]. Resident #60 had orders to monitor her blood pressure and pulse prior to administering antihypertensive medications; a nurse failed to obtain and record the resident's blood pressure and pulse prior to administering these medications as ordered by the physician. The nurse also failed to record the resident's blood sugar level as indicated on the physician's orders [REDACTED].#60. Facility census: 59. Findings include: a) Resident #60 Review of the Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. No evidence could be found that Employee #70 followed the physician's orders [REDACTED]. Further review of the MAR found initials indicating a nurse obtained Resident #60's blood sugar at 8:00 p.m. on 07/29/11, but there was no record of the blood sugar level itself. Interview with the director of nursing, at 1:00 p.m. on 08/24/11, confirmed Employee #70 did not document a blood sugar, pulse, or blood pressure of Resident #60 for this date and time. . | 2014-12-01 |
| 10725 | 10725 | GLEN WOOD PARK, INC. | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-08-24 | 282 | D | 1 | 0 | HTIL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure qualified nursing staff had knowledge of a resident's code status, for one (1) of six (6) sampled residents. Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Record review revealed Resident #60 had elected to be a full code. Review of the nurses' notes from [DATE] through [DATE] revealed the following entries (quoted as written): - On [DATE] at 8:30 p.m.: "Resident in bed call light in reach. Took meds with no problems or distress. Taking oxygen off face. Instructed to leave on face. Resident stated, 'I don't want that on my face.' oxygen saturation was 93%. Lung sounds clear. Will continue to monitor." - On [DATE] at 10:00 p.m.: "Resident hollering to be turned. Staff goes in to turn resident when leaving she wants to be turned again. Continues to remove oxygen. Vitals 97.3, 107, 26, ,[DATE]." - On [DATE] at 12:00 a.m.: "Resting in bed - call light within reach. Yelling out to be turned - before nursing assistant can leave room pt in yelling again. Pt. yelling, 'God Help me.' When ask if she was hurting pt. states, 'no' VS (vital signs) WNL (within normal limits). oxygen saturation 94% Lungs clear. oxygen in use as ordered. - cont to remove oxygen tubing from nostril." - On [DATE] at 1:20 a.m.: "cont to yell out and move around in bed - [MEDICATION NAME] given per prn (as needed) order. cont. to remove oxygen from nostrils - lungs clear. nursing assistant sitting at bedside to give comfort to pt." - On [DATE] at 2:00 a.m.: "remains in bed. quiet at present. Requires assist with ADL's (activities of daily living), foley (indwelling urinary catheter) patent and draining dark yellow urine." - On [DATE] at 2:40 a.m.: "Had light on - nursing assistant went into room - resident asked to be pulled up in bed. oxygen off - replaced pat. was trying to remove oxygen when nursing assistant was putting it on patient stated, "I don't want this on my… | 2014-12-01 |
| 10726 | 10726 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 156 | B | 0 | 1 | H9I611 | . Based on a review of the facility's Medicare demand bill records and staff interview, the facility failed to provide the appropriate beneficiary liability and appeal notices for three (3) of three (3) residents who had recently had their Medicare-covered services terminated. There was no evidence that the facility notified the beneficiary of his/her potential liability for payment and standard appeal rights. This practice affected Resident #40 and had the potential to effect more than an isolated number of residents who received Medicare-covered services. Facility census: 49. Findings include: a) Resident #40 Record review of residents who had received Medicare-covered services in the last three (3) months revealed one (1) demand bill had been requested. This was for Resident #40. The letter used to notify the resident / responsible party that services would no longer be covered by Medicare was a letter designed by the facility which did not contained all required elements found in Form CMS- or one (1) of the five (5) uniform denial letters found in the CMS Skilled Nursing Manual. The letter sent by the facility did not notify the legal representative of the beneficiary's potential liability for payment of the non-covered services. An interview with the staff member responsible for patient accounts (Employee #130) confirmed the facility was not utilizing the CMS forms to notify residents / responsible parties of Medicare non-coverage and of their right to request demand bills, which contained all of the required information for notification to the beneficiary. . | 2014-12-01 |
| 10727 | 10727 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 279 | D | 0 | 1 | H9I611 | . Based on observation, record review, and staff interview, the facility failed to develop a care plan to address the oral / dental care needs of one (1) of twenty-three (23) Stage II sample residents. The care plan for Resident #33 did not describe how to provide oral care to this resident, who resisted opening her mouth and clenched her jaws tightly together when the caregivers attempted to perform oral hygiene. Her care plan also did not address the need for an evaluation by a dentist to assure the resident, who had blackened / broken teeth, did not experience pain or impairment in her eating ability as a result of her poor dental status. Resident identifier #33. Facility Census: 49. Findings include: a) Resident #33 While in the dining area at 2:00 p.m. on 10/11/10, observation found Resident #33 with her head tilted back and her mouth opened, which allowed this surveyor to see she had several teeth missing. She had one (1) black tooth in poor condition in the right upper side of her mouth; there were no other teeth present in that area. She also had two (2) broken teeth in the front on the bottom that were just barely above the gum line. Review of Resident #33's medical record found no evidence that a complete oral examination had been performed on this resident. She was admitted to the facility 06/12/06. On 10/13/10 at 4:00 p.m., a licensed practical nurse (LPN - Employee #88) was asked to perform an oral exam on this resident, so the inside of her mouth could be further observed. Employee #88 attempted to use a tongue depressor to view the inside of Resident #33's mouth; the resident did not want to open her mouth and resisted attempts to view inside her mouth. The resident finally allowed the nurse to look briefly inside her mouth, and the nurse confirmed the resident's teeth were in poor condition. The nursing assistant providing care for the resident on 10/13/10 (Employee #50), when interviewed at 5:00 p.m., was questioned about providing oral care for this resident. Employee #50 stated this resident of… | 2014-12-01 |
| 10728 | 10728 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 412 | D | 0 | 1 | H9I611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to identify the need, and arrange dental services, for one (1) of twenty-three (23) Stage II sample residents, to assure she was not experiencing complications (such as pain or infection) related to the poor condition of her oral cavity. This resident was observed to have multiple broken, carious teeth which had not been identified as a concern by the facility, and for which no referral had been made to a dentist for possible intervention. Resident identifier: #33. Facility census: 49. Findings include: a) Resident #33 While in the dining area at 2:00 p.m. on 10/11/10, observation found Resident #33 with her head tilted back and her mouth opened, which allowed this surveyor to see she had several teeth missing. She had one (1) black tooth in poor condition in the right upper side of her mouth; there were no other teeth present in that area. She also had two (2) broken teeth in the front on the bottom that were just barely above the gum line. Review of Resident #33's medical record found no evidence that a complete oral examination had been performed on this resident. She was admitted to the facility 06/12/06. On 10/13/10 at 4:00 p.m., a licensed practical nurse (LPN - Employee #88) was asked to perform an oral exam on this resident, so the inside of her mouth could be further observed. Employee #88 attempted to use a tongue depressor to view the inside of Resident #33's mouth; the resident did not want to open her mouth and resisted attempts to view inside her mouth. The resident finally allowed the nurse to look briefly inside her mouth, and the nurse confirmed the resident's teeth were in poor condition. The nursing assistant providing care for the resident on 10/13/10 (Employee #50), when interviewed at 5:00 p.m., was questioned about providing oral care for this resident. Employee #50 stated this resident often would not allow her to provide oral care and woul… | 2014-12-01 |
| 10729 | 10729 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 431 | E | 0 | 1 | H9I611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and policy review, the facility failed to assure medications were stored safely under proper temperatures and failed to dispose of outdated medications to prevent them from being unsafely administered to residents. These practices were present in two (2) of two (2) medication storage rooms and had the potential to affect more than an isolated number of residents. Facility census: 49. Findings include: a) Observation of the facility's medication rooms, on [DATE] beginning at 10:00 a.m., found the temperatures of the refrigerators used to store medications were not monitored consistently to assure the medications were stored at safe temperatures. This was true for both of the medication storage rooms. The refrigerator in the medication room serving Unit A did not have evidence of temperature monitoring from [DATE] to [DATE]. The temperature of the refrigerator in the medication room serving Units B and C was monitored on only three (3) of twelves (12) days month-to-date in October. The director of nursing (DON), when interviewed on [DATE] at 1:00 p.m., verified the refrigerators' temperature logs were not completed and said it was the facility's practice to record the temperatures on evening shift daily, to make sure medications requiring refrigeration were stored at a proper temperature. - b) Review of the facility's storage of medications in the medication room serving Units B and C, in the company of a licensed practical nurse (LPN - Employee #55 at 10:00 a.m. on [DATE], found multiple medications that were outdated. These medications were as follows: - Magnesium Oxide 400 mg - three (3) bottles with expirations dates of [DATE] - Bacteriostatic Sodium Chloride 30 mg 0.9% 30 ml with an expiration date of [DATE] - Mineral Oil 30 ml containers - seven (7) containers with expiration dates of ",[DATE]" - Acetaminophen 650 mg rectal suppositories - twenty seven (27) suppositories with expiration dates of ",… | 2014-12-01 |
| 10730 | 10730 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 371 | F | 0 | 1 | H9I611 | . Based on observation, staff interview, and review of the USDA Food Code, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The practices have the potential to affect all residents who receive nourishment from dietary services. Facility census: 49. Findings include: a) Observation of the automatic dishwasher, on 10/11/10 at 9:40 a.m., found the rinse cycle water temperature reached 208 degrees Fahrenheit (F). The recommended temperature posted on the outside of the machine was 180 degrees F. Review of the dishwasher temperatures log maintained by the facility revealed the rinse cycle water temperature had exceeded 180 degrees F one fifty-three (53) occasions between 10/01/10 and 10/11/10. On 10/11/10 at 10:00 a.m., an interview with the dietary manager (Employee #19) revealed she was unaware that the dishwasher had a maximum rinse cycle water temperature. Review of the USDA Food Code revealed: "The temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 190 degrees or less than." Employee #19 and a member of the maintenance department (Employee #124) provided information from Hobart (a service vendor) that the dishwasher's temperature gauge was reading 25 degrees F higher than the internal temperature. The temperature gauge was subsequently replaced on 10/12/10. - b) On 10/13/10 at 10:55 a.m., an observation of the kitchen found cleaning cloths with bleach water on them where on the table where two (2) staff members were preparing parsley for garnishes and where other food preparation was also being done on the table. On 10/14/10 at 9:15 a.m., Employee #19 confirmed that cleaning cloths and solutions should not be on the table when food preparation was occurring. - c) On 10/13/10 at 10:55 a.m., an observation of the kitchen revealed steam table pans that were ready for use had debris inside which could be scraped off with a fingernail, and baking pans had heavy layers of charred food and/or grease d… | 2014-12-01 |
| 10731 | 10731 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 441 | E | 0 | 1 | H9I611 | . Based on observation and staff interview, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection. Observations in the dining room during the evening meal found staff members did not wash their hands upon entering the dining room and/or after handling potentially contaminated items. This practice has the potential to affect more than an isolated number of residents. Facility census: 49. Findings include: a) During the evening meal in the dining area on 10/12/10 at 5:15 p.m., observation found a nursing assistant (NA - Employee #90) assisting a male resident from a Merriwalker to a stationary chair. This NA did not wash her hands before handling milk containers and eating utensils. Also on 10/12/10 at 5:15 p.m., observation found another NA (Employee #70) picking a clothing protector off the floor. She did not wash her hands before handing food containers and food. On 10/12/10 at 5:30 p.m., Employee #60 (NA) handled the trash can in the dining room and did not wash her hands before handling food. An interview with the director of nursing, on 10/12/10 at 5:45 p.m., confirmed these practices were unsanitary. . | 2014-12-01 |
| 10732 | 10732 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 323 | E | 0 | 1 | H9I611 | . Part I -- Based on observation, review of the facility's material safety data sheets (MSDS), and staff interview, the facility failed to provide a resident environment as free of accident hazards as is possible, by failing to secure against unauthorized access rooms that contained hazardous chemicals and/or materials. These included rooms containing biohazardous waste, soiled linen, products for resident care, and/or housekeeping chemicals that may be harmful if ingested or if they came into contact with a resident's skin or eyes. This practice had the potential to affect more than a minimal number of residents on the A, B and C units who were cognitively impaired and had the ability to be independently mobile about the floor whether in a wheelchair or on foot. Facility census: 49. Findings include: a) During a random tour of the facility on 10/14/10 at approximately 9:42 a.m., two (2) surveyors observed two (2) doors, to rooms labeled as biohazardous on the B and C units of the facility, were unlocked and accessible to residents. Stored in these rooms were dirty linens from the units, trash from the units, a large red sharps container that could accommodate a resident's hand, and resident care products and housekeeping products, each with the precautionary labels stating "... hazardous to humans and domestic animals. Causes moderate eye irritation." Following this observation, a tour of the A wing discovered the door to a janitor's closet was also unlocked and accessible. Inside this closet were stored Clorox Germicidal Bleach, PROFI Floor Cleaner/Oil & Grease Remover, WIWAX Cleaning & Maintenance Emulsion, Purell Instant Hand Sanitizer Foam, Stride Citrus SC (Super Concentrate), GP FORWARD SC (Superconcentrate), VIREX II 256. Review of the MSDS for these products found precautionary statements that, at a minimum, stated the products "may be mildly irritating to eyes and skin". The maximum health hazard identification statements for at least two (2) of the products found they were "corrosive and may cause perm… | 2014-12-01 |
| 10733 | 10733 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 463 | D | 0 | 1 | H9I611 | . Based on observation and staff interview, the facility failed to assure the nurse call system was working in a room occupied by two (2) of forty (40) Stage I sample residents. Resident identifiers: #2 and #54. Facility census: 49. Findings include: a) Residents #2 and #54 Testing of the nurse call system, during Stage I of the survey on 10/12/10 at 2:00 p.m., found the call system serving the room shared by Residents #2 and #54 did not function properly. When the call lights were activated at bedside, the nurse call system did not respond with a visual or auditory signal. Staff repaired the nurse call system immediately when this matter was brought to their attention on 10/12/10. | 2014-12-01 |
| 10734 | 10734 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 334 | E | 0 | 1 | H9I611 | . Based on medical record review, facility policy review, and staff interview, the facility failed, for five (5) of five (5) residents reviewed, to assure the resident or the resident's legal representative was provided information regarding the benefits and potential side effects of influenza immunization prior to the administration of the vaccine. This practice has the potential to affect more than an isolated number of residents in the facility. Resident identifiers: #33, #9, #21, #19, and #14. Facility census: 49. Findings include: a) Residents #33, #9, #21, #19, and #14 When reviewed on 10/13/10 at 2:00 p.m., the facility's influenza / pneumonia vaccine practices for Residents #33, #9, #21, #19, and #14 included no method of informing the resident / responsible party of the benefits and potential side effects of the vaccines. The facility's infection control nurse (Employee #44), when interviewed on 10/13/10 at approximately 2:30 p.m., confirmed the facility did not currently have a method of informing the resident or resident's legal representative of the benefits and potential side effects of influenza immunization prior to administering the vaccine. . | 2014-12-01 |
| 10735 | 10735 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 278 | D | 0 | 1 | H9I611 | . Based on observation, record review, and staff interview, the facility failed to assure the dental status of one (1) of twenty-three (23) Stage II sample residents was accurately encoded in the resident's minimum data set (MDS) assessment to reflect the presence of broken, carious teeth. Resident identifier: #33. Facility census: 49. Findings include: a) Resident #33 While in the dining area at 2:00 p.m. on 10/11/10, observation found Resident #33 with her head tilted back and her mouth opened, which allowed this surveyor to see she had several teeth missing. She had one (1) black tooth in poor condition in the right upper side of her mouth; there were no other teeth present in that area. She also had two (2) broken teeth in the front on the bottom that were just barely above the gum line. Review of Resident #33's medical record found no evidence that a complete oral examination had been performed on this resident. She was admitted to the facility 06/12/06. On 10/13/10 at 4:00 p.m., a licensed practical nurse (LPN - Employee #88) was asked to perform an oral exam on this resident, so the inside of her mouth could be further observed. Employee #88 attempted to use a tongue depressor to view the inside of Resident #33's mouth; the resident did not want to open her mouth and resisted attempts to view inside her mouth. The resident finally allowed the nurse to look briefly inside her mouth, and the nurse confirmed the resident's teeth were in poor condition. Review of the resident's most recent MDS, a comprehensive annual assessment with an assessment reference date of 06/06/10, found the assessor noted, in Section L, that the resident had some teeth lost and did not have or use dentures. The items in Section L to identify any broken, loose, or carious teeth was not marked. The MDS nurse (Employee #44), when interviewed at 4:30 p.m. on 10/13/10, verified the resident's annual MDS had been encoded incorrectly with respect to her dental status. The MDS nurse also verified that the monthly nursing summaries completed … | 2014-12-01 |
| 10736 | 10736 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2011-08-11 | 282 | G | 1 | 0 | H2M211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on closed medical record review, hospital record review, and staff interview, the facility failed, for one (1) of thirteen (13) residents reviewed, to provide care and services, as determined necessary by a comprehensive assessment and plan of care and/or in accordance with accepted standards of practice, to avoid physical harm. Resident #105 did not receive adequate care related to her diabetes as outlined in her plan of care, and abnormal lab values were not appropriately communicated to her attending physician. This lack of care resulted in a critically high abnormal blood sugar level, rendering the resident unconscious and requiring hospitalization . Facility census: 104. Findings include: a) Resident #105 When reviewed on 08/09/11, the closed medical record of Resident #105 revealed this 89-year ol female had been admitted to the facility' neighboring acute care hospital on [DATE], when she fell at home, where she lived alone, and fractured her left wrist. According to the hospital "history and physical examination [REDACTED]. This document also stated that the resident had additional medical [DIAGNOSES REDACTED]. The resident was admitted to the hospital and underwent a "closed reduction and casting of the left wrist" the following day. A "Progress Notes" document from the acute care hospital, signed by a hospital physician and dated 03/25/11, stated: "Afebrile, doing well, OK for transfer." The resident was admitted to BJHCCC on 03/25/11 at 15:30 (3:30 p.m.). Her [DIAGNOSES REDACTED]. The resident was ordered no diabetic medication or monitoring when admitted to the nursing home. -- Documentation on the admission nursing assessment noted, on Page 4 of 5 in the area that describes level of consciousness, that the resident had clear speech, made her self understood, was able to express ideas and wants, and was able to understand verbal content. Nurses notes at the nursing home immediately began describing the resident a… | 2014-12-01 |
| 10737 | 10737 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2011-08-11 | 225 | D | 1 | 0 | H2M211 | . Based on review of facility complaint records, review of allegations of abuse / neglect, and staff interview, the facility failed to report four (4) allegations of abuse / neglect / misappropriation of property received in the previous six (6) months to the State agency and other appropriate agencies according to State law. Resident identifiers: #24, #107, and #105. Facility census: 104. Findings include: a) Resident #24 Review of all self-reported allegations of abuse / neglect submitted to State agencies by the facility in the previous six (6) months revealed a document identified as a "Patient Complaint", which contained a summary of complaints registered by a family member of Resident #24 on 05/19/11. The document stated Resident #24 had been "assaulted by another resident", was not being taken to the bathroom, was not receiving assistance when the call light was activated, and was experiencing repeated falls due to lack of supervision and assistance. The facility's administrator (Employee #9) had contacted the family member by phone to discuss this complaint, but there was no evidence to reflect the allegations of abuse and neglect contained in the complaint had been reported to the appropriate State agencies. When interviewed on 08/10/11 at approximately 4:00 p.m., the facility's administrator confirmed these allegations had not been reported as required. -- b) Resident #107 Review of all self-reported allegations of abuse / neglect submitted to State agencies by the facility in the previous six (6) months revealed a document identified as "Patient / Family Complaints", which was written on 06/20/11. The document stated that, while Resident #107 was no longer at the facility, the facility received a report from a family member of events the resident stated had occurred while at the facility. The resident alleged that "when he asked to be put to bed they wouldn't do it and when they did put him in bed they didn't care how the got him in bed - just threw him in and kicked him." Facility staff had documented… | 2014-12-01 |
| 10738 | 10738 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2011-08-11 | 505 | D | 1 | 0 | H2M211 | . Based on closed record review and staff interview, the facility, failed for one (1) of thirteen (13) sampled residents, to promptly notify the attending physician of the abnormal findings of lab reports. Resident #105 had a urinalysis on 04/30/11 and blood work on 04/18/11. Both lab studies yielded abnormal results, with the urinalysis yielding critically elevated results, and there was no evidence to reflect staff had promptly notified the physician of the findings of either lab. Resident identifier: #105. Facility census: 104. Findings include: a) Resident #105 When reviewed on 08/09/11, the closed medical record of Resident #105 disclosed a nurse's note dated 04/30/11 at 1830 (6:00 p.m.), which stated: "St (straight) cathed (catheterized) for U/A (urinalysis) /c (with) reflex. Sent to lab at 1815 (6:15 p.m.)." Further review revealed no result for this lab test was found on the resident's record. When interviewed on 08/10/11 at 8:30 a.m., the facility's director of nurses (DON - Employee #7) was not aware that lab results were not on the record. Employee #7 obtained the result from the lab and provided evidence that the test had been completed as ordered. The results of this urinalysis, once obtained, disclosed that the resident had glucose in her urine. The report stated "C - Critical Result", and the level was noted to be 1000 MG/DL, with normal values stated to be 0 MG/DL. Employee #9 could not provide evidence that the resident's attending physician had been made aware of the findings of the test, which contained critical level abnormalities. - Other lab studies, completed earlier on 04/18/11, also contained abnormal results - with blood glucose level was 301 (normal reference range is 74 to 106). There was no mention in the resident's medical record of this abnormal lab finding having been called to the resident's physician. . | 2014-12-01 |
| 10739 | 10739 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2011-08-11 | 492 | E | 1 | 0 | H2M211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to ensure that all physician-ordered medications (including medical gases) were administered by qualified personnel, by permitting (contrary to State law) unlicensed staff to start, regulate, and administer oxygen. This was found to have affected one (1) former resident (#106) and has the potential to affect five (5) current residents who were prescribed continuous oxygen (#108, #109, #68, #111, and #24) and more than a minimal number of future residents. Facility census: 104. Facility census: 104. Findings include: a) Resident #106 1. Review of the facility's self-reported allegations of abuse / neglect, on 08/09/11 at 9:00 a.m., disclosed a report involving Resident #106, with an incident date of 10/26/10. The date of the immediate FAX reporting of allegations was 10/26/10. The allegation was stated (quoted as written): "Pt (patient) states 11-7 CNA (certified nursing assistant) that worked last night got her ready for [MEDICAL TREATMENT] Early AM (morning) and did not put pt's oxygen on her. Pt asked CNA to connect her to her oxygen and CNA said 'Oh, you don't need that.' Pt stated that she had said this before to her." The five day follow-up report, dated 10/28/10 and completed by the facility's unit manager (Employee #83), stated (quoted as written): "I showed resident pictures of the 2 nursing assistants that worked 11-7 shift on North hall on 10/25/2010-10/26/2010. (Resident #106) pointed to (Employee #159)'s photo picture. 'She is the one who did not put oxygen on me, even after I asked her for it.' I called (Employee #159) at home with the DON (director of nursing - Employee #7) present (on speakerphone) to question her about the incident. (Employee #159) admitted that she did not put oxygen on the patient. 'No one ever puts oxygen on her when she goes to [MEDICAL TREATMENT]. They put it on her in [MEDICAL TREATMENT]. (Resident #106) never asked me to put… | 2014-12-01 |
| 10740 | 10740 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2011-08-11 | 507 | D | 1 | 0 | H2M211 | . Based on closed record review and staff interview, the facility, failed for one (1) of thirteen (13) sampled residents, to file the results of a urinalysis obtained on 04/30/11. Resident identifier: #105. Facility census: 104. Findings include: a) Resident #105 When reviewed on 08/09/11, the closed medical record of Resident #105 disclosed a nurse's note dated 04/30/11 at 1830 (6:00 p.m.), which stated: "St (straight) cathed (catheterized) for U/A (urinalysis) /c (with) reflex. Sent to lab at 1815 (6:15 p.m.)." Further review revealed no result for this lab test was found on the resident's record. When interviewed on 08/10/11 at 8:30 a.m., the facility's director of nurses (DON - Employee #7) was not aware that lab results were not on the record. The results of this urinalysis, once obtained, disclosed that the resident had glucose in her urine. The report stated "C - Critical Result", and the level was noted to be 1000 MG/DL, with normal values stated to be 0 MG/DL. Employee #9 could not provide evidence that the resident's attending physician had been made aware of the findings of the test, which contained critical level abnormalities. . | 2014-12-01 |
| 10741 | 10741 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2011-08-11 | 224 | G | 1 | 0 | H2M211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, hospital record review, and staff interview, the facility failed, for one (1) of thirteen (13) residents reviewed, to provide care and services, as determined necessary by a comprehensive assessment and plan of care and/or in accordance with accepted standards of practice, to avoid physical harm. Resident #105 did not receive adequate care related to her diabetes as outlined in her plan of care, and abnormal lab values were not appropriately communicated to her attending physician. This lack of care resulted in a critically high abnormal blood sugar level, rendering the resident unconscious and requiring hospitalization . Facility census: 104. Findings include: a) Resident #105 When reviewed on 08/09/11, the closed medical record of Resident #105 revealed this 89-year ol female had been admitted to the facility' neighboring acute care hospital on [DATE], when she fell at home, where she lived alone, and fractured her left wrist. According to the hospital "history and physical examination [REDACTED]. This document also stated that the resident had additional medical [DIAGNOSES REDACTED]. The resident was admitted to the hospital and underwent a "closed reduction and casting of the left wrist" the following day. A "Progress Notes" document from the acute care hospital, signed by a hospital physician and dated 03/25/11, stated: "Afebrile, doing well, OK for transfer." The resident was admitted to BJHCCC on 03/25/11 at 15:30 (3:30 p.m.). Her [DIAGNOSES REDACTED]. The resident was ordered no diabetic medication or monitoring when admitted to the nursing home. -- Documentation on the admission nursing assessment noted, on Page 4 of 5 in the area that describes level of consciousness, that the resident had clear speech, made her self understood, was able to express ideas and wants, and was able to understand verbal content. Nurses notes at the nursing home immediately began describing the resident as "alert w… | 2014-12-01 |
| 10742 | 10742 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2011-08-25 | 166 | E | 1 | 0 | 36XK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's grievance / complaint reports, family interview, resident interview, and staff interview, the facility failed to make prompt efforts resolve grievances. There was no evidence of a thorough investigation into grievances filed by (or on behalf of) two (2) of six (6) sampled residents and four (4) random residents identified through a review of twenty-two (22) grievance reports reviewed. Resident identifiers: #136, #7, #158, #106, #24, #31, and #137. Facility census: 154. Findings include: a) Resident #136 Review of grievance / complaint reports found a report filed by a family member dated 07/05/11, stating (quoted as written): "Daughter reported concerns of the resident in the room next to her mother and her screaming all of the time. ..." Under the heading "Documentation of Facility Follow-up", and in response to the question "What other action was taken to resolve this concern (be specific)?", the author wrote: "Informed (name of family member filing complaint) we were working /c (with) (name of Resident #155) & collaboration /c Admin, DON (director of nursing),Soc Serv & myself." Under the heading "Resolution of Grievance / Complaint", in response to the question "Was the grievance /complaint resolved?", the person completing the form checked "Yes" and noted (quoted as written): "... 3) (name of family member filing complaint) was advised of above re (regarding) (name of Resident #155)." The author also noted she had a one-to-one conversation with the persona filing the complaint about this resolution on 07/08/11. An interview was conducted with the family member on 08/24/11 at 2:00 p.m., she stated the grievance regarding the resident in the next room (#155) was still an issue, that there had been no resolution of this issue, and that the residents in the vicinity of the room of this resident were complaining. According to the family member, this has been an on-going unresolved issued for the past six … | 2014-12-01 |
| 10743 | 10743 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2011-08-25 | 258 | E | 1 | 0 | 36XK11 | . Based on observation, review of complaint files, family interview, resident interview, confidential staff interview, and staff interview, the facility failed to provide for the maintenance of comfortable sound levels for residents who were disturbed by another resident's yelling. This affected more than an isolated number of residents. Resident identifiers: #136, #48, #106, and #45. Facility census: 154. Findings include: a) Review of complaint files revealed a complaint by Resident #136's medical power of attorney representative (MPOA), dated 07/05/11, about "concerns of the resident in the room next to her mother and her screaming all of the time". Further review of this complaint revealed the "resolution" was to inform the MPOA that the administrator, director of nursing (DON), social services, and the nurse manager were collaborating and working with the resident who was yelling out (Resident #155). -- b) Resident #136 During an interview with Resident #136's MPOA on 08/24/11 at approximately 2:30 p.m., she said she met with the nurse manager and the DON about Resident #155's yelling, but there has been no improvement or resolution. She said if someone sits with Resident #155, she doesn't yell. Resident #136 agreed that Resident #155 yells "all the time". - Observation from within Resident #136's room with the door closed, on 08/24/11 from 2:50 p.m. to 2:54 p.m., found Resident #155 yelled audibly forty-one (41) times; from 3:03 to 3:08 p.m. she yelled audibly thirty-seven (37) times. Observations made periodically on 08/24/11 and 08/25/11 found this to be a frequent behavior. -- c) Resident #48 During an interview with Resident #48 on 08/24/11 at 3:30 p.m., he stated Resident #155, who is two (2) doors down, yells a lot and "keeps everybody awake". He said the yelling awakens him five (5) to six (6) nights per week and, as a result, he feels tired the next day; she yells during the day, but it is worse at night. He stated he complained to one (1) of the nursing assistants, spoke to someone in the office, a… | 2014-12-01 |
| 10744 | 10744 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2011-08-25 | 280 | D | 1 | 0 | 36XK11 | . Based on record review, family interview, and staff interview, the facility failed to revise a care plan for one (1) of six (6) sampled residents after it was made known that the female resident and/or her medical power of attorney representative (MPOA) did not want a male staff member performing catheterizations on the resident. Resident identifier: #136. Facility census: 154. Findings include: a) Resident #136 Record review of a nursing progress note, dated 08/21/11, revealed the MPOA for Resident #136 "keeps insisting" the resident does not want a male staff member performing catheterizations on her, although the resident herself did not such voice complaints. During an interview on 08/24/11 at approximately 2:30 p.m., Resident #136's MPOA stated the resident was catheterized once over the past weekend by a male nurse (Employee #46), and the resident allegedly cried because she did not want a male to perform the catheterization. The MPOA reported that Resident #136 requires a catheterization three (3) times daily (once each shift) to relieve residual urine, and her nephrologist advised against having a permanent indwelling catheter inserted. During an interview with a licensed social worker (LSW - Employee #169) on 08/24/11 at 11:20 a.m., she said no one had reported to her about Employee #46 catheterizing the resident against the resident's (or the MPOA's) wishes, nor had she received a request for a female nurse to perform the procedure instead of a male. Review of the resident's care plan revealed no revision to the interventions in acknowledgement of the MPOA and/or the resident's request to have only a female nurse perform catheterizations. Interview with the director of nursing and a nurse manager, on 08/25/11 at approximately 11:50 a.m., revealed they were unaware that Resident #136 and/or her MPOA did not want a male to perform catheterizations. | 2014-12-01 |
| 10745 | 10745 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-08-31 | 155 | D | 1 | 0 | H3XI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the advance directives of one (1) of six (6) sampled residents were honored by the facility. Resident #94's expressed her wishes with respect to advance directives in writing prior to losing the capacity to make her own informed medical decisions. The facility permitted the resident's medical power of attorney representative (MPOA) to change these written instructions for end-of-life care after the resident was no longer able to express her wishes. Facility census: 93. Findings include: a) Resident #94 A review of Resident #94's closed medical record revealed she was admitted to the facility on [DATE]. On 05/08/11, the physician determined she possessed the capacity to make her own informed health care decisions. Further record review disclosed a combined WV Advance Directive / Living Will / Medical Power of Attorney document, which had been completed and signed by Resident #94 on 03/13/07. This form contained the following: "If I should reach a point when I lack capacity to make medical decisions, am in a terminal state, or become permanently unconscious or remain in a permanent vegetative state I have indicated my wishes by my initials on the lines below." In the section of the document labeled Living Will, the resident indicated she did not want life prolonging treatment and wished to be permitted to die naturally with only the administration of any medication or the performance of any medical treatment deemed necessary to alleviate pain. Regarding the administration of artificial nourishment, the resident stated, "I do not want artificially provided water or other artificially provided nourishment or fluids (tube feedings intravenous fluids etc)." The form had an area labeled "Special Directions or Limitations", in which the resident indicated she wanted to be kept comfortable and was to be a DNR (do not resuscitate). In the section designating a medical power of … | 2014-12-01 |
| 10746 | 10746 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2009-07-22 | 280 | D | 0 | 1 | UHKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to revise the care plans for two (2) of twenty-five (25) Stage II sampled residents. Two (2) residents, who recently had a significant weight loss, did not have their care plans revised to reflect the current interventions staff was implementing to monitor weight and prevent a further decline. Resident identifiers: #120 and #133. Facility census: 122. Findings include: a) Resident #120 Resident #120's medical record, when reviewed on 07/22/09 at 9:00 a.m., disclosed a [AGE] year old male who was admitted to the facility on [DATE]. The medical record stated the resident's admission weight, on 02/26/09, was 169 pounds. The resident's weight, on 07/18/09, was reported to be 154 pounds. The resident had a significant weight loss of 8.8 % in a four (4) month period of time. The resident's current care plan, with a revision date of 06/04/09, did not include all current interventions the facility staff was implementing to prevent further weight loss. The dietary manager (Employee #12), when interviewed on 07/22/09 at 11:00 a.m., reported the facility staff was implementing interventions to monitor the resident's weight and prevent a further decline. The dietary manager reviewed the current care plan (with a revision date of 06/04/09) and confirmed all current interventions were not listed on the current care plan. The care plan nurse (Employee #32), when interviewed on 07/22/09 at 2:00 p.m., reviewed the resident's current plan of care (with a revision date of 06/04/09) and confirmed the resident's current care plan was not revised to include all current interventions the staff was implementing to improve weight and prevent further decline. b) Resident #133 Resident #133's medical record, when reviewed on 07/22/09 at 10:00 a.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The resident's medical record stated the resident's weight, on 04/04/09, … | 2014-12-01 |
| 10747 | 10747 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2009-07-22 | 311 | D | 0 | 1 | UHKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, record review, staff interview, and resident interview, the facility did not ensure that one (1) resident of a sample of twenty-five (25) received care and services to maintain or enhance the resident's ability to ambulate. Resident #80 had a physician's orders [REDACTED]. Facility census: 122. Findings include: a) Resident #80 An interview with Resident #80, on 07/22/09 at 9:30 a.m., revealed the resident wanted the nursing assistants to assist her with ambulation. The resident stated, "The aides used to walk me, but they don't do it any more. I want to walk out in the hall, and they don't take me any more for my walk, and I need someone with me." An interview with the assessment coordinator (Employee #32), on 07/14/09 at 10:10 a.m., revealed the resident had an order to ambulate with a wheeled walker daily. She stated that, after talking with the nursing assistants, this morning they were not walking the resident every day. She was starting the resident on a walk-to-dine program that would require the nursing staff to walk the resident to the dining room for meals on a daily basis. Record review revealed a physician's orders [REDACTED]." A review of the facility's Resident Flow Record revealed the documentation was not accurate for the resident's ambulation. The nursing assistants were marking the area for ambulation with the word "up". An interview with a registered nurse (Employee #36), on 07/14/09 at 10:30 a.m., revealed the documentation for the resident's ambulation was not clear as to what was happening with the resident concerning her daily ambulation. She was uncertain as to how the nursing assistants were documenting. The form revealed that each day the nursing assistants were marking "up", and the RN did not have an explanation for the documentation. An interview with a licensed practical nurse (Employee #40), on 07/22/09 at 11:30 a.m., revealed a treatment aide usually ambulated the residents on the 3:00 … | 2014-12-01 |
| 10748 | 10748 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2009-07-22 | 492 | C | 0 | 1 | UHKM11 | Based on observation, facility records, and staff interview, the facility failed to post the nurse staffing as required by Section 941 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), which requires skilled nursing facilities and nursing facilities to post daily for each shift the number of registered nurses, licensed practical nurses, and unlicensed nursing staff directly responsible for resident care in the facility. This had the potential to affect all residents. Facility census: 122. Findings include: a) During the general tour at 1:00 p.m. on 07/20/09, observation revealed the nursing staffing posting contained only the number of licensed and unlicensed staff and total full-time equivalents (FTEs) for each shift. The posting failed to differentiate the categories of nursing staff by differentiating between licensed practical nurses and registered nurses. During an interview with the administrator and the director of nurses at 4:00 p.m. on 07/22/09, this lack of information was pointed out and they were given the source of the requirement. | 2014-12-01 |
| 10749 | 10749 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2009-07-22 | 371 | E | 0 | 1 | UHKM11 | Based on observation and staff interview, the facility failed to assure all kitchens contained hands-free garbage disposal equipment for dietary employee use at hand-washing stations. This was evident for one (1) of the two (2) kitchens and had the potential to affect all residents on the 500 Hall who receive nourishment from that kitchen. Facility census: 122. Findings include: a) During the initial tour on 07/20/09, an attempt to discard a used paper towel revealed the step-on trash can at the employee handwashing station in Kitchen #2 was not functioning. A dietary staff member (Employee #180) directed the surveyor to throw her paper towel onto a tray of food that she was going to discard. On 07/21/09 at 11:30 a.m., observation of Kitchen #2 revealed no trash receptacle at the employee handwashing station. Further observation of Kitchen #2 found a large black, round plastic trash can with a fitted lid in the dishwashing area. There were no other trash receptacles in the kitchen. On 07/22/09 at 4:00 p.m., a repeat observation of Kitchen #2 again found no trash receptacle at the employee hand-washing station. This surveyor reported the observation to Employee #12, and she explained that the step-on trash can broke yesterday. She threw her paper towel into the large black, round plastic trash can with a fitted lid that was housed in the dishwashing area. This surveyor did the same but could not avoid touching the trash can with her hand as she disposed of a used paper towel. . | 2014-12-01 |
| 10750 | 10750 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 279 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop a plan of care to address the care and treatment of [REDACTED]. The staff caring for this resident was not aware she had a drug-resistant infection in her eyes and nares. There was no evidence that the facility had a plan to alert staff and visitors of special precautions needed with respect to having contact with the resident's body secretions. This affected one (1) of thirteen (13) sampled residents . Resident identifier: #32. Facility census: 75. Findings include: a) Resident #32 Review of Resident #32's medical record revealed she was admitted to the hospital on [DATE], for an altered level of consciousness. According to her hospital records, she had had a fever and drainage from her eyes, and she tested positive for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in her right eye and her nares. She was receiving antibiotics for her nares and her eyes and was still receiving this treatment when she came back to the nursing home. Observation of this resident revealed she was not in any type of isolation, and her care plan did not identify any special precautions to be taken when interacting with or caring for this resident. During an interview with the infection control nurse (Employee #26) on 06/24/09 at 3:00 p.m., she was made aware of the resident's infections. She confirmed this was missed when the resident returned from the hospital; the resident's infections were not record on the facility's infection control log, and no isolation precautions were initiated when she returned from the hospital. She also confirmed Resident #23 should have been placed in isolation. This resident's room was observed at 9:00 a.m. on 06/25/09. The nursing assistant was observed taking special precautions prior to entering the room to care for this resident. There was a sign placed on the door to see the nurse before entering the room. These precautions were … | 2014-12-01 |
| 10751 | 10751 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 328 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure Resident #72 received the proper respiratory care and treatment. Staff failed to utilize proper technique to administer a nebulizer treatment to a resident with a [MEDICAL CONDITION] (trach). Staff also did not ensure this resident's oxygen was administered in accordance with physician's orders [REDACTED]. Proper respiratory care and treatment was not provided for one (1) of thirteen (13) sampled residents. Resident identifier: #72. Facility census: 75. Findings include: a) Resident #72 1. During an observation of the medication administration for Resident #72 on 06/23/09, this resident was observed to have an order for [REDACTED].# 81) administered this treatment by holding a face mask over the resident's trach. Observation found the medicated aerosol coming out the sides of the mask, with very little actually going into [MEDICAL CONDITION]. The nurse, when questioned about the use of this mask, stated they have special tubing for the trach, but they were out and did not have the right ones available. The assistant director of nursing (ADON), when interviewed on 06/23/09, was asked to provide the facility's policy and procedure for administering a nebulizer treatment to a resident with a trach. The ADON provided a policy for administering hand-held nebulizer treatments but stated they did not have a policy for administering a nebulizer via a trach. The ADON reported they have a respiratory person who comes in and provides them with the equipment they need and shows them how to use it. She stated the facility does have special tubing and [MEDICAL CONDITION] to use for the residents with trachs. 2. Further observations of this resident, throughout the day on 06/23/09 and 06/24/09, revealed this resident did not use her oxygen during those days. The resident's O2 saturation, when checked, was at 98%. A review of the resident's medical record revealed [REDACTED].@ (at) four … | 2014-12-01 |
| 10752 | 10752 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 333 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents were free from significant medication errors. The nurse was preparing to administer 60 mg of the anticoagulant medication [MEDICATION NAME], instead of the 45 mg dose ordered by the physician. Receiving too much of this medication could result in internal hemorrhaging. Significant medication errors were found for one (1) of ten (10) residents observed during medication pass. Resident identifier: #66. Facility census: 75. Finding include: a) Resident #66 During medication administration, observation found a nurse (Employee #81) preparing medications for Resident #66. Review of the labels found a pre-filled syringe of [MEDICATION NAME] 60 mg /0.6 ml. The directions on the medication label stated to administer 0.5 ml (50 mg) sub-Q ( subcutaneously) bid (twice a day). While the nurse was preparing her medications, surveyor observed Resident #66's Medication Administration Record [REDACTED]." The nurse was observed to complete her preparation. As she was preparing to administer the medications to the resident, the surveyor intervened and asked the nurse to stop and double check the label against the MAR. The nurse then verified the dose she was preparing to administer was not correct. The nurse then calculated the correct dose and wasted the excess medication that was in the syringe. The nurse proceeded to tell the surveyor they had discussed this, but the [MEDICATION NAME] did not come from the pharmacy in the dose ordered. . | 2014-12-01 |
| 10753 | 10753 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 441 | F | 0 | 1 | 667111 | Based on a review of the facility's policies and procedures for infection control and isolation for residents with infections, observations of residents with infections, and staff interview, the facility failed to develop and implement an effective infection control program to prevent the potential spread of infections in the facility. The facility's policies and procedures were not periodically reviewed and revised to reflect changes in standards of practice, and the existing procedures were not consistently implemented to prevent the spread of infectious organisms. The facility's did not maintain a record of all residents with infections, including the infectious organism found and/or the type of isolation precaution to be used. The number of residents at the facility with facility-acquired (nosocomial) infections had increased, but there was no evidence to show the facility investigated this increase in nosocomial infections for the causative factors or implemented measures to prevent further incidents of residents contracting nosocomial infections. The absence of an effective infection control program placed all residents residing in the facility at risk of acquiring an infection. Facility census: 75. Findings include: a) Infection Control Program Review of the facility's infection control policies and procedures revealed the policies were not thorough and were not consistently implemented. The infection control policy (which did not contain an effective date) stated the purpose of the policy was to ensure the infection control program was effective for investigating, controlling, and preventing infections in order to provide a safe sanitary, and comfortable environment. The procedure for this stated the following: "1. LPN (Licensed Practical Nurse) on duty will report any signs / symptoms of infection to the physician. Along with any other information requested. "2. Obtain order for treatment. Check ER (emergency) box to see if medication ordered can be obtained. If not STAT medication to facility. "3. Notif… | 2014-12-01 |
| 10754 | 10754 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 226 | C | 0 | 1 | 667111 | Based on a review of the facility's policy titled "reporting abuse" and staff interview, the facility failed to ensure its "reporting abuse" policy addressed the identification, reporting, and prevention of resident neglect. This practice had the potential to affect all facility residents. Facility census: 75. Findings include: a) On 06/23/09 at approximately 10:00 a.m., the facility's policy titled "reporting abuse" was reviewed. The policy did not identify what constituted resident neglect, nor did it address how, when, or who would report such situations within the facility, and to what State agencies they would be reported outside of the facility. The policy also did not explain how the facility would prevent neglect from occurring. The policy basically only gave an understanding on what constituted abuse and how the facility would proceed with identifying, preventing, and reporting allegations involving abuse. The facility social worker and director of nurses both agreed the policy did not address allegations of resident neglect, including identification, reporting, and prevention. . | 2014-12-01 |
| 10755 | 10755 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 152 | E | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure, for three (3) of thirteen (13) sampled residents, a legal surrogate was appointed in accordance with State law for residents lacking the capacity to understand and make their own informed health care decisions. Determinations of incapacity were made solely based on a [DIAGNOSES REDACTED]. Resident identifiers: #50, #33, and #47. Facility census: 75. Findings include: a) Resident #50 On 06/24/09 at approximately 2:00 p.m., review of Resident #50's medical record revealed a physician's determination of capacity form indicating Resident #50 lacked the capacity to understand and make informed health care decisions. However, the cause of the incapacity had not been recorded on the form. b) Resident #47 On 06/23/09, review of Resident #47's medical record revealed a physician's determination of capacity form indicating Resident #47 lacked the capacity to understand and make informed health care decisions due to having a [DIAGNOSES REDACTED]. c) Resident #33 Review of Resident #33's medical record, on 06/23/09, revealed the physician determined she lacked the capacity to understand and make her own health care decisions; however, the cause of her incapacity was not recorded. d) According to '16-30-7. Determination of incapacity., "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a … | 2014-12-01 |
| 10756 | 10756 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 465 | F | 0 | 1 | 667111 | Based on observation and staff interview, the facility failed to maintain an environment for residents that was in good repair. All but one (1) hallway had doors in need of repair, the surface of an isolation table was unclean and in poor repair, and Resident #58's room and nursing equipment were not maintained in a sanitary manner. Facility census: 75. Findings include: a) On 06/25/09 at approximately 10:00 a.m., a tour of the inside of the building revealed the corridor doors of resident rooms were scarred and had some type of substance on them. The administrator said the doors had holes that had been filled (but not finished), and the filler was the substance that had been noted. He agreed the doors were not in good condition and commented that they were replacing the doors one (1) at a time, and he hoped to have all of them replaced soon. b) An isolation table was also observed to be in poor repair on the 200 hallway. The table was beaten and scratched up and appeared dirty. c) Resident #58 Observation, during a tour of the facility on 06/25/09, revealed Resident #58's room contained a suction machine that was not clean. The wall area in this room was also dirty, with splashes that ran down the wall. d) On 06/25/09 at approximately 1:00 p.m., the administrator indicated he was unaware of the dirty equipment and condition of the walls in Resident #58's room as well as the soiled table on the 200 hallway. The administrator indicated the areas and equipment would be cleaned as soon as possible. . | 2014-12-01 |
| 10757 | 10757 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 309 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents received medication in an amount as ordered by the treating physician. Resident identifier: #21. Facility census: 75. Findings include: a) Resident #21 During observations of the medication administration pass on 06/23/09 at 8:50 a.m., the nurse was monitored while preparing Resident #21's medications. The nurse was noted to place a [MEDICATION NAME] 325 mg (Iron) tablet into a plastic medication administration cup with her other medications. Review of the Medication Administration Record [REDACTED]. As the nurse locked her cart and prepared to enter the resident's room, she was asked to review the MAR. She agreed the resident should not be administered the [MEDICATION NAME] and discarded the medication. . | 2014-12-01 |
| 10758 | 10758 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 371 | F | 0 | 1 | 667111 | Based on observations and staff interview, the facility failed to ensure proper sanitation procedures were employed for manual warewashing, freezer units had internal thermometers to ensure food items were being stored at proper temperatures, and food (ice) was being handled with clean utensils when served. These practices have the potential to affect all residents, as all residents who consume food by oral means are served from this central location. Facility census: 75. Findings include: a) During the initial tour of the kitchen on the afternoon of 06/23/09, observation found the walk-in freezer did not contain an internal thermometer to ensure correct temperature levels were being maintained for safe storage of frozen foods. b) Also during the tour, observation found dietary staff had placed a sanitizer tablet in the water of the three-compartment sink for manual warewashing; the tablet had not dissolved. The surveyor questioned staff about the method used to sanitize, and the dietary staff indicated they used tablets that would dissolve in the water to the make the right concentration of sanitizer. Review of the manufacturer's directions for use of the tablets revealed staff needed to increase the amount of water in the sanitizing compartment of the three-compartment sink and use hot water to dissolve the tablets. The dietary manager and the consultant dietitian were present and instructed the staff member to add more water and use two (2) tablets, not one (1). Additionally, they directed the staff member to use hot water, not just warm water from the tap. c) During observations of the medication pass on 06/23/09 at 9:35 a.m., the nurse was observed to pour water (for a resident to take medications) from a clear plastic pitcher. Observation of the water pitcher noted the inner rim beneath the pitcher was coated with a black layer of grime. This same substance was present on the inner portion of the plastic handle. The nurse agreed the pitcher was not clean and stated she had not noticed it. She obtained a cle… | 2014-12-01 |
| 10759 | 10759 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 492 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and review of the West Virginia Health Care Decisions Act, the facility failed to ensure the physician orders [REDACTED]. Resident identifiers: #26 and #77. Facility census: 75. Findings include: a) Resident #26 Review of the medical record found a POST form completed on [DATE]. Section A was documented the resident was to receive cardiopulmonary resuscitation (CPR) should he suffer cardiac or [MEDICAL CONDITION] arrest. Further review noted Section B directed the resident receive comfort measures. This section specifically states: "Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location." The two (2) sections, as completed, conflicted with the resident's wishes to receive treatment to support cardiac and [MEDICAL CONDITION] function. The POST form did not comply with the West Virginia Health Care Decisions Act [DATE](b) which states, "...in accordance with that person's wishes...". b) Resident #77 The medical record of this female resident contained a POST form dated "2/ /09" (date was incomplete), which was not signed by either the resident or the resident's legal surrogate for health care decisions. This was discussed with the office manager on the afternoon of [DATE], who verified the form was incomplete and that there was not way to determine whether the directives otherwise noted on the form reflected the actual wishes of the resident. . | 2014-12-01 |
| 10760 | 10760 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 161 | E | 0 | 1 | 667112 | Based on a review of the facility's surety bond and staff interview, the facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. Facility census: 77. Findings include: a) A review of the facility's surety bond revealed the facility had increased the amount of the bond from $20,000 to $40,000 to assure the security of the residents' personal funds. There was no evidence this new surety bond had been approved by the AG for sufficiency of form and amount, as required. The administrator verified, at 09/07/09 at 4:00 p.m., the bond with the new amount had not been approved by the AG's office. . | 2014-12-01 |
| 10761 | 10761 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 225 | E | 0 | 1 | 667112 | Based on a review of the facility's reported abuse investigations and staff interview, the facility failed to ensure an allegation of neglect was thoroughly investigated. Resident #78's family reported the resident had arrived at 2:00 p.m. on 08/22/09, and they reported to the nurse at 6:00 p.m. that no staff member had been in her room since she arrived. The report also stated an indwelling Foley urinary catheter bag had been put in the bed with the resident. During the investigation, a written statement by the nursing assistant providing care for the resident on 08/22/09 indicated the family told her a "shake" was also thrown in the corner of the sink and not given to the resident. A review of the investigation into allegations of neglect involving this resident revealed no evidence to reflect the allegations related to the nutritional supplement not being given and the Foley catheter bag laying in the resident's bed were further investigated. The investigation was not thorough for one (1) of three (3) allegations of neglect that were reported. Resident identifier: #78. Facility census: 77. Finding include: a) Resident #78 According to the facility's abuse reporting records, on 08/22/09, Resident #78's son came to the nurse and wanted to see the charge nurse. That nurse told him she was the charge nurse, and he asked her to come in the resident's room. When the nurse went in the room, he told her his mother (Resident #78) had arrived at the facility at 2:00 p.m. that day, and no staff member had turned her since she arrived and that a Foley catheter bag had been put in bed with the resident. This was at 6:00 p.m. on 08/22/09, and he wanted to make sure this did not happen again. This incident was reported to the State agencies including the nurse aide registry for the nursing assistant responsible for providing care to the resident at that time. A review of the facility's investigation found the family member told the nursing assistant there was a "shake" (nutritional supplement) for 2:00 p.m. that was "thrown"… | 2014-12-01 |
| 10762 | 10762 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 508 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain radiology services in a timely manner as ordered by the treating physician for one (1) of thirteen (13) sampled residents. Resident identifier: #60. Facility census: 75. Findings include: a) Resident #60 Review of the medical record found a 02/19/09 physician's orders [REDACTED].-resistant Staphylococcus aureus (MRSA) had cleared. Review of the medical record found no evidence the facility had obtained the ordered radiology service for this resident. The director of nursing (DON) provided information which stated the CT would have been scheduled on 03/03/09. During an interview conducted on 06/25/09 at 9:15 a.m., the DON agreed staff should have either obtained the CT scan or called the physician. . | 2014-12-01 |
| 10763 | 10763 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-09-10 | 332 | E | 0 | 1 | 667112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and a review of the manufacturer's instructions for administration, the facility failed to assure it was free of medication error rates of greater than 5%. The facility had a medication error rate of 12.5 %. Medications not administered in accordance with the physician's orders [REDACTED]. Additionally, a nurse prepared to administer the incorrect vitamins, and a resident was not instructed to rinse his mouth out with water following the administration of the [MEDICATION NAME] Diskus. There were forty (40) opportunities with a total of five (5) medication errors observed. Resident identifiers: #75, #6, #63, and #47. Facility census: 77. Findings include: a) Resident #75 During the medication pass observation on 09/09 2009 at 9:00 a.m., the nurse (Employee #15) administered medications to Resident #75, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. b) Resident #6 During the medication pass observation on 09/09 2009 at 9:15 a.m., Employee #15 administered medications to Resident #6, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. c) Resident #63 During the medication pass observation on 09/09/09 at 9:20 a.m., the nurse administered medications to Resident #63, including the inhalant [MEDICATION NAME]. The nurse administered the [MEDICATION NAME] discus and then closed the Diskus and put it back in the cart. The nurse failed to instruct the resident to rinse his mouth out with water and spit after the administration of this medication. The nurse, when questioned about rinsing out the resident's mouth, she stated she was not aware that they had to do this. A review of the instruction sheet provided with … | 2014-12-01 |
| 10764 | 10764 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-09-10 | 520 | F | 0 | 1 | 667112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gathered on a revisit through observation, record review, and staff interview, the facility failed to implement a plan of action to correct identified quality deficiencies. The facility failed to correct deficient practices in six (6) of the same areas after the facility submitted an acceptable plan of correction indicating these concerns would be resolved prior to the end of August 2009. Repeat deficiencies were found in the areas of protection of residents funds, abuse investigating and reporting, care planning, medication errors, infection control, and isolation. This practice has the potential to affect all of the residents in this facility. Facility census: 77. Findings include: a) The facility's plan of correction for the standard survey completed on 06/25/09 was reviewed; however, deficient practices remained within respect to the following: 1. The facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. See citation at F161. 2. The facility failed to ensure an allegation of neglect was thoroughly investigated. The investigation was not thorough for one (1) of three (3) allegations of neglect that were reported. See citation at F225. 3. The facility failed to develop a plan of care to include the precautions to be taken during the care of residents who had a drug resistant infection. This was true for three (3) of three (3) residents reviewed who had a drug-resistant infection. See citation at F279. 4. The facility failed to administer a medication as ordered by the physician. This was a significant medication error affected one (1) of ten (10) sampled residents. See citation at F333. 5. The facility failed to implement an effective infection control program to prevent the potential spread of infections in the facility. The absence of an effective infect… | 2014-12-01 |
| 10765 | 10765 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-11-18 | 514 | B | 0 | 1 | 667113 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to utilize the correct reporting forms for submitting initial and five (5) day follow-up reports for allegations of resident abuse / neglect to the State survey agency's Nursing Home Program; failed to incorporate all necessary data onto one easy-to-read form for infection control tracking; and failed to ensure a transcription error did not occur for one (1) of forty-three (43) observed medication administrations. Facility census: 73. Findings include: a) Review of the facility's abuse policy, on 11/17/09, revealed, on page 3 Item #5 "Investigation and Reporting", the facility's plan to send immediate fax reportings of allegations and five (5) day follow-up reports to the State survey agency's Nurse Aide Abuse Registry. Review of all the self-reported allegations and their respective investigations for September, October, and November 2009 revealed several were submitted using the Nurse Aide Abuse Registry's reporting forms for instances where a nursing assistant was not involved in the alleged event and the Nursing Home Program's reporting forms (which is a separate program within the same State survey agency) should have been used, as follows: 09/13/09 involving Resident #34; 09/20/09 involving Resident #69; 09/24/09 involving Resident #34; 09/25/09 involving Resident #2; 09/29/09 involving Resident #67; and 10/04/09 involving Resident #25. Five (5) of the above events were related to unknown perpetrators, and one (1) event (dated 09/13/09) was related to a licensed practical nurse. In all of the cases, no allegations of abuse or neglect were substantiated. During interview with the director of nursing on 11/18/09 at 9:00 a.m., the above findings were discussed, and she received a copy of the two-page Table 1 - Abuse / Neglect Reporting Requirements for WV Nursing Homes and Nursing Facilities revised August 2009. She stated the social worker completes and faxes the five (5) day… | 2014-12-01 |
| 10766 | 10766 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2010-04-22 | 279 | D | 0 | 1 | UDOR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, record review, and staff interview, the facility failed to develop a comprehensive plan of care to address all care and services needs of one (1) of thirty-seven (37) Stage II sample residents. Resident #72 had bilateral knee contractures and self-care deficits, but these issues were not addressed on her current care plan. Resident identifier: #72. Facility census: 94. Findings include: a) Resident #72 The registered nurse (RN - Employee #74), when interviewed on the afternoon of 04/14/10, reported Resident #72 did have contractures with no current order for a splint or range of motion (ROM) therapeutic exercises. Review of the resident's medical record, on 04/15/10 at 10:00 a.m., disclosed she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her current care plan, dated 03/31/10, revealed neither her self-care deficits nor the presence of bilateral knee contractures was included in the plan. Resident #72 was observed in bed at 10:00 a.m. on 04/19/10. The resident was alert and verbal. The resident's knees were observed to be flexed in a fixed position. When asked if she could extend her legs, she reported she could not. The care plan nurse (Employee #31), when interviewed on 04/19/10 at 10:15 a.m., reviewed the current care plan and acknowledged the resident's self-care deficit needs and bilateral knee contractures were not addressed. The MDS nurse stated she would revise the care plan to include knee contractures and her self-care deficits. On 04/21/10, the MDS nurse provided a copy of the resident's revised care plan dated 04/19/10. The revised care plan reported the resident required extensive assistance with activities of daily living and was dependent on staff for assistance. The revised care plan also noted the resident has decreased mobility due to contractures of bilateral lower extremities and contained interventions to be implemented to improve function and prevent furth… | 2014-12-01 |
| 10767 | 10767 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2010-04-22 | 318 | G | 0 | 1 | UDOR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, observation, resident interview, and record review, the facility failed to provide appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in range of motion for a resident with limited ROM for one (1) of thirty-seven (37) Stage II sample residents. There was no evidence a resident, who developed bilateral knee contractures since her admission to the facility, received the necessary care and treatment to increase her ROM and/or prevent a further decline. This deficient practice resulted in actual harm to Resident #72. Facility census: 94. Findings include: a) Resident #72 1. The registered nurse (RN - Employee #74), when interviewed on the afternoon of 04/14/10, reported Resident #72 did have contractures with no current order for a splint or range of motion (ROM) therapeutic exercises. 2. Record review, on 04/19/10 at 9:30 a.m., revealed a quarterly minimum data set assessment (MDS) with an assessment reference date of 03/19/10, on which the assessor noted the resident had limited range of motion (ROM) to one (1) leg with no loss of voluntary movement. This assessment information was contradicted by the physician's annual history and physical examination [REDACTED]. The assessment and care planning nurse (Employee #31), when interviewed on 04/19/10 at 10:15 a.m., reviewed the 03/19/10 quarterly MDS and acknowledged it was inaccurate with respect to limitations in the resident's ROM. Employee #31 stated she "just missed the contracture on the nurse's quarterly assessment, and the therapy screen reported no changes". (See citation at F272.) 3. Resident #72's current care plan, dated 03/31/10, did not address the presence of bilateral knee contractures. Employee #31, when interviewed on 04/19/10 at 10:15 a.m., reviewed the current care plan and acknowledged the resident's bilateral knee contractures were not addressed, stating she would revise the care plan to include knee… | 2014-12-01 |
| 10768 | 10768 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2010-04-22 | 281 | D | 0 | 1 | UDOR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure that services provided to its residents met professional standards of quality for two (2) of thirty-seven (37) Stage II sample residents. One (1) resident received an incorrect dose of medication, and the facility failed to obtain a physician's order for hospice services for another resident. Resident identifiers: #47 and #21. Facility census: 94. Findings include: a) Resident #47 Observation, at 4:20 p.m. on 04/14/10, found a licensed practical nurse (LPN - Employee #44) administering medications to Resident #47. The LPN gave Resident #47 one (1) capsule [MEDICATION NAME] formula dosage- 60K/12K. The medical record, when reviewed on the morning of 04/15/10, revealed the current physician order was for three (3) capsules [MEDICATION NAME] formula 60K/12K three (3) times a day with meals. The LPN unit manager (Employee #94), when interviewed on 04/16/10 at 9:00 a.m., acknowledged Employee #44 gave the incorrect dose of medication. The correct order was for three (3) capsules of Creon. According to the "Medical Office of Pharmacology: Review for medical assistant students and Professionals, Safety Guidelines - The Five Rights", the five rights of medication administration are: 1. Right patient. 2. Right time and frequency of administration. 3. Right dose. 4. Right route of administration. 5. Right drug. (Internet resource web address: http://www.mapharm.com/safety.) The facility failed to ensure the right dose [MEDICATION NAME] administered to Resident #47. b) Resident #21 A review of Resident #21's medical record failed to find a physician's order for the Hospice services he had been receiving since 12/17/09. The director of nurses, when informed of this at 10:00 a.m. on 04/21/10, stated she would review the chart for the order. No physician's order for Hospice services for Resident #21 was found at the time of exit from the facility on 04/22/10. . | 2014-12-01 |
| 10769 | 10769 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2010-04-22 | 253 | E | 0 | 1 | UDOR11 | Based on observation, staff interview, resident interview, and family interview, the facility failed to provide effective housekeeping and/or maintenance services to assure a resident environment free from persistent, unpleasant odors. Repeated observations during the course of this survey event from 04/13/10 through 04/22/10, found the presence of strong urine odors on the Hilltop wing and the facility's Alzheimer's specialty unit. This had the potential to affect more than an isolated number of residents. Facility census: 94. Findings include: a) Hilltop wing During general tour beginning at 11:30 a.m. on 04/13/10, this surveyor detected the odor of stale urine on the Hilltop wing in the hallway from Room #133 through Room #146. The odor did not appear to emanate from any individual resident room(s) and seemed centered in the hallway. This odor was present on each day of the survey. During an interview at 9:15 a.m. on 04/15/10, the daughter of Resident #3 stated there were often odors that "smell like urine" in the hallway outside of her mother's room. In an interview with Resident #301 in her room, she also mentioned the odor of urine in the hall outside of her room. In an interview with Resident #76 at 11:05 a.m. on 04/20/10, she stated she liked her room and where it was located, but she wished they could get rid of the odor of urine in the hall. A strong odor of urine was also present daily in the hall outside of the "break room / medical records". During an interview with the interim administrator, the nurse consultant, and the newly hired administrator at 3:30 p.m. on 04/21/10, they were made aware of these findings. No one denied the odors were present. The interim administrator stated the facility was trying very hard to eliminate these odors and speculated that a part of the problem may be in the brand of incontinence pads in use. b) Alzheimer's specialty unit During initial tour of the Alzheimer's unit on 04/13/10, a pervasive pungent odor of urine was noted throughout the entire unit. The carpeting t… | 2014-12-01 |
| 10770 | 10770 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2010-04-22 | 329 | D | 0 | 1 | UDOR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of thirty-seven (37) Stage II sample residents, to ensure the resident's medication regimen was free from unnecessary drugs given without adequate indications for use. Resident #81 was seeing a consultant psychiatrist on an outpatient basis every two (2) months; per family request, this consultant physician was the only person permitted to make changes to her psychoactive medications. There was no documentation in the resident's medical record by the consultant physician of the clinical rationale for continued use of antianxiety and antipsychotic medications. Resident identifiers: #81. Facility census: 94. Findings include: a) Resident #81 Medical record review, on 04/20/10, revealed Resident #81 received [MEDICATION NAME] 0.5 mg by mouth every six (6) hours as needed for anxiety, [MEDICATION NAME] 2.5 mg two (2) times a day an 8:00 a.m. and 2:00 p.m. due to behavioral disturbances, and [MEDICATION NAME] 5 mg by mouth every night for behavioral disturbances. According to the medical record, her behaviors were stable for the past year. Additional information in the medical record revealed only the consultant physician was permitted to make any changes in the resident's medications. No information could be found in the medical record concerning any consultations this resident had with this physician. In an interview on 04/10/10 at 2:36 p.m., a licensed practical nurse (LPN - Employee #79) identified that, a year ago, Resident #81 had some serious problem behaviors. The family now comes in every two (2) months and takes her to their own physician; if changes are needed in her medications, he makes them. Otherwise, this consultant physician does not make any documentation in the medical record, nor does he review the resident's overall medical record. Employee #79 also reported that, for about the past year, Resident #81's behaviors have been stable. In an inte… | 2014-12-01 |
| 10771 | 10771 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2010-04-22 | 225 | E | 0 | 1 | UDOR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based upon personnel record review and staff interview, the facility failed to verify whether prospective employees have a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This was found for nine (9) of ten (10) employees' personnel records reviewed. Employee identifiers: #24, #80, #93, #104, #40, #74, #39, #47, and #20. Facility census: 94. Findings include: a) Employees #24, #80, #93, #104, #40, #74, #39, #47, and #20 When reviewed on 04/19/10 at 11:00 a.m., four (4) of five (5) sampled personnel records (Employees #24, #80, #93, #104) reviewed lacked verification that the State nurse aide registry had been checked prior to employment. When reviewed on 04/20/10 at 10:00 a.m., five (5) of five (5) sampled personnel records (Employees #40, #74, #39, #47, #20) reviewed lacked verification that the state nurse aide registry had been checked prior to employment. During an interview on 04/20/10 at 10:13 a.m., the payroll person (Employee #72) stated the facility was checking the State nurse aide registry on prospective nursing assistants only, but they will now initiate the registry check on all potential employees. . | 2014-12-01 |
| 10772 | 10772 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2010-04-22 | 272 | D | 0 | 1 | UDOR11 | . Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the accuracy of a quarterly assessment for one (1) of thirty-seven (37) Stage II sample residents. A resident's quarterly abbreviated minimum data set (MDS) assessment was inaccurate regarding physical functioning and structural problems related to contractures of the lower extremities. Resident identifier: #72. Facility census: 94. Findings include: a) Resident #72 The registered nurse (RN - Employee #74), when interviewed on the afternoon of 04/14/10, reported Resident #72 did have contractures with no current order for a splint or range of motion (ROM) therapeutic exercises. Record review, on 04/19/10 at 9:30 a.m., revealed a quarterly MDS with an assessment reference date (ARD) of 03/19/10, on which the assessor noted the resident had limited range of motion (ROM) to one (1) leg with no loss of voluntary movement. This assessment information was contradicted by the physician's annual history and physical examination [REDACTED]. Resident #72 was observed in bed at 10:00 a.m. on 04/19/10. The resident was alert and verbal. The resident's knees were observed to be flexed in a fixed position. When asked if she could extend her legs, she reported she could not. The nurse aide (Employee #103), when interviewed on 04/19/10 at 10:15 a.m., confirmed the resident had bilateral knee contractures with no orders for ROM activities by nursing staff or the application of a splint. The MDS nurse (Employee #31), when interviewed on 04/19/10 at 10:15 a.m., reviewed the 03/19/10 MDS and acknowledged the MDS was inaccurate for limitations in ROM. The MDS nurse stated she "just missed the contracture on the nurse's quarterly assessment, and the therapy screen reported no changes". On 04/21/10 at 1:00 p.m., the MDS nurse provided a copy of the corrected MDS with a correction date of 04/19/10. The corrected MDS assessment identified the resident currently had limited ROM with full loss of voluntary movement to both lower ex… | 2014-12-01 |
| 10773 | 10773 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2010-06-30 | 323 | D | 0 | 1 | UDOR12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and policy review, the facility failed to ensure the resident environment remained as free of accident hazards of was possible for one (1) of twelve (12) sampled residents. One (1) resident was observed on two (2) separate days to have medication left at the bedside without direct supervision of a nurse. Resident identifier: #21. Facility census: 97. Findings include: a) Resident #21 Observation, during initial tour of the facility shortly after 11:00 a.m. on 06/28/10, found Resident #21 asleep in her bed with the privacy curtain closed half way and an Advair inhaler lying on her chest. There were no nurses in the room at this time. A nurse (Employee #59) was immediately summoned from the hall by the surveyor. Upon entrance to the room, Employee #59 woke the resident and asked if she had used the inhaler; the resident replied in the affirmative, and the inhaler was removed from the room. Observation, on 06/30/10 at approximately 9:00 a.m., found Resident #21 awake in her room finishing breakfast with the privacy curtain closed half way and with an Advair inhaler lying on her overbed tray. When questioned, the resident said the nurse left the inhaler yesterday sometime after the evening meal. A nurse (Employee #17) was immediately summoned from the hall by the surveyor, and she removed the inhaler. Employee #17 stated she had not yet given Resident #21's morning medications and inhaler. She checked the medication administration record (MAR) and confirmed this resident receives Advair inhaler once in the morning and once in the evening. Review of active physician orders revealed an order for [REDACTED]. There were no physician's orders allowing this resident to self-administer medication. Review of the resident's most recent minimum data set (MDS) assessment, dated 06/14/10, found the answer to be "No" under Section S, "Capable of self-administration of medications". On 06/30/10 at 10:30 a.m., the direct… | 2014-12-01 |
| 10774 | 10774 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2011-08-03 | 312 | D | 1 | 0 | LP7S11 | . Based on observation, staff interview, record review, and family interview, the facility failed to provide necessary services to maintain good grooming and personal hygiene for dependent residents as evidenced by a one (1) of eleven (11) sampled residents with long, untrimmed toenails and one (1) of eleven (11) sampled residents with stains on his shirt not changed in a timely manner following a meal. Resident identifiers: #64 and #24. Facility census: 95. Findings include: a) Resident #64 Observation of Resident #64's toenails, with assistance of nursing assistant (Employee #123) on 08/03/11 at 8:50 a.m., revealed all toenails on both feet were long and in need of trimming. The right great toenail was thickened and misshapened, with a graying discoloration of the nail bed. The left great toenail was long and curved inward toward the second toe, making an indentation on the skin at the corner of the second toe nailbed. The skin on the second toe was not open at this time. Interview with a nurse (Employee #111), on 08/03/11 at 8:55 a.m., found the facility contracted with a podiatrist who comes to the facility usually once per month in the middle of the month to trim residents' toenails. Employee #111 stated the nurses do weekly body audits and summaries on residents, and the interdisciplinary team does skin assessments monthly. The floor nurses and treatment nurse follow-up any identified issues, and the treatment nurse has the podiatry list. Employee #111 stated the most recent skin assessment for Resident #64 was completed on 07/27/11. Record review revealed the absence of any podiatry consultation reports on Resident #64's medical record. On 08/03/11 at 9:00 a.m., Employee #111 stated Resident #64 was admitted to and had resided on the Solano unit (Alzheimer's unit) since 05/05/11 until a hospitalization occurred in early July; following discharge from the hospital, she was readmitted to the Hilltop unit on 07/14/11. Employee #111 stated that, upon her re-admission on 07/14/11, a body audit was completed, bu… | 2014-12-01 |
| 10775 | 10775 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2011-08-03 | 323 | E | 1 | 0 | LP7S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and observation, the facility failed to ensure the environment was as free as possible of accident hazards for three (3) of eleven (11) sampled residents and one (1) randomly observed resident who were observed ambulating on laminate and/or tiled floor in footwear that was not non-skid. Resident identifiers: #64, #18, #36, and #54. Facility census: 95. Findings include: a) Resident #64 Record review revealed Resident #64 experienced a fall while ambulating in the hallway of the Solana (Alzheimer's) unit, which resulted in a fractured hip and transfer to the hospital on [DATE]. - Review of the facility's incident / accident report investigation revealed Employee #61 (a nurse), who was in charge of the unit at the time of the fall, reported Resident #64 was wearing socks, but she did not think they were non-skid socks. Also, she reported there was nothing on the floor that would have potentially caused the fall. Review of the fall investigation worksheet revealed this resident had an unsteady gait, was confused, was wearing socks at the time of the fall, and had experienced a fall in the preceding thirty (30) days. - Review of Resident #64's care plan revealed a focus area for risk for falls. An intervention on the care plan was: "Resident to wear non slip footwear" (which was initiated was 05/05/11). - Review of a history and physical examination [REDACTED]"may have slipped while wearing socks and fell from a standing position". - Interview with the director of nursing (DON) and the licensed social worker (LSW), on 08/02/11 at 2:45 p.m., revealed the facility had no policy prohibiting residents from walking in socks that were not non-skid if that was what the family brought in for them to wear. The DON stated the use of non-skid socks was a nursing intervention if it looked like a potential problem. The DON and the LSW agreed Resident #64's earlier fall on 06/28/11 was a fall out of bed. - In an inter… | 2014-12-01 |
| 10776 | 10776 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2011-08-31 | 323 | G | 1 | 0 | 5Y7411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for two (2) of forty-four (44) residents reviewed, to provide adequate supervision and/or assistive devices to prevent accidents, resulting in actual harm to one (1) of these residents. The interdisciplinary team developed a care plan to address risk of falls for Resident #84, who was admitted on [DATE] with poor coordination, impaired balance, unsteady gait, moderately impaired cognitive functioning, and multiple psychiatric diagnoses. Interventions to prevent falls included both environmental modifications (e.g., keep room clutter-free, keep commonly used items nearby, etc.), as well as interventions that relied on the resident to remember to ask for assistance and to exercise good judgment to promote her own safety. After she experienced her first fall in the facility on 07/11/11, a physical therapy screen recognized that the resident's poor safety awareness and impulsive behavior, as well as her instability, put her at risk for falling; however, the care plan was not revised to address these issues. Resident #84 sustained a second fall on 07/28/11, resulting in a contusion to the forehead requiring transfer to the emergency room . The interdisciplinary team also developed a care plan to address risk of falls for Resident #34, who had a [DIAGNOSES REDACTED]. The care plan interventions to promote safety required the resident to recall information (such as reminding her to ask for staff assistance, relying on her to remember to use a call bell, and educating her on safety risks), which were not appropriate for this resident. Review of incident / accident reports revealed she sustained fourteen (14) falls since her admission to the facility on [DATE]. Resident identifiers: #84 and #34. Facility census: 100. Findings include: a) Resident #84 When reviewed on 08/24/11, the medical record for Resident #84 divulged this resident was admitted to the facility on [DATE]. According t… | 2014-12-01 |
| 10777 | 10777 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2011-08-04 | 204 | D | 1 | 0 | S9PC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, staff interview, and interview with staff at the local hospital, the facility failed to provide sufficient preparation and notice to a resident and her family to ensure an orderly discharge from the facility in a manner that minimizes unnecessary and avoidable anxiety. This was found for one (1) of eight (8) residents' whose records were reviewed. Resident identifier: #43. Facility census: 41. Findings include: a) Resident #43 Closed record review revealed Resident #43 was an [AGE] year old woman who was admitted to the facility on [DATE]. She was transferred to the Behavioral Health Unit at a local hospital for evaluation on 06/26/11, and subsequently discharged permanently from the nursing home on 07/11/11. - The facility's social worker (Employee #34), when interviewed about the 07/11/11 discharge of Resident #43 on 08/02/11 at 2:00 p.m., stated the facility discharged the resident due to concerns about elopements and aggressive behavior. She stated the resident was sent to the Behavioral Health Unit following an elopement on 06/26/11 that had found her some distance away from the facility. A member of the community returned the resident to the facility. The social worker stated the resident had not returned to this nursing home, and the Behavioral Health Unit had discharged her to another nursing facility in Grafton. - Nurses' notes, when reviewed on 08/04/11 at 8:41 a.m., found an entry by a licensed practical nurse (LPN - Employee #68) dated 06/26/11, stating (quoted as written): "3:10pm, received call from a (name of person from community), that she found resident on Market Street by Wes Banco bank. (Name of person from community) brought resident back to facility. Resident very unsteady on her feet and sat down in the nearest chair. Resident continues to say 'They are all jealous of me because I have the spaghetti sauce from Muriales and they don't' Also 'I am getting out of here no matter w… | 2014-12-01 |
| 10778 | 10778 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2011-08-04 | 202 | D | 1 | 0 | S9PC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, staff interview, and interview with staff at the local hospital, the facility failed to adequately document the reasons and conditions surrounding a resident's discharge from the facility due to safety reasons. This was found for one (1) of eight (8) residents' whose records were reviewed. Resident identifier: #43. Facility census: 41. Findings include: a) Resident #43 Closed record review revealed Resident #43 was an [AGE] year old woman who was admitted to the facility on [DATE]. She was transferred to the Behavioral Health Unit at a local hospital for evaluation on 06/26/11, and subsequently discharged permanently from the nursing home on 07/11/11. - The facility's social worker (Employee #34), when interviewed about the 07/11/11 discharge of Resident #43 on 08/02/11 at 2:00 p.m., stated the facility discharged the resident due to concerns about elopements and aggressive behavior. She stated the resident was sent to the Behavioral Health Unit following an elopement on 06/26/11 that had found her some distance away from the facility. A member of the community returned the resident to the facility. The social worker stated the resident had not returned to this nursing home, and the Behavioral Health Unit had discharged her to another nursing facility in Grafton. - Nurses' notes, when reviewed on 08/04/11 at 8:41 a.m., found an entry by a licensed practical nurse (LPN - Employee #68) dated 06/26/11, stating (quoted as written): "3:10pm, received call from a (name of person from community), that she found resident on Market Street by Wes Banco bank. (Name of person from community) brought resident back to facility. Resident very unsteady on her feet and sat down in the nearest chair. Resident continues to say 'They are all jealous of me because I have the spaghetti sauce from Muriales and they don't' Also 'I am getting out of here no matter what you have to say'. Attempted to redirect resident, which… | 2014-12-01 |
| 10779 | 10779 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2011-08-04 | 280 | D | 1 | 0 | S9PC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to review and revise a resident's care plan as the resident's status changed, with input from all appropriate staff and family. This was found for one (1) of eight (8) residents sampled. Resident identifier: #43. Facility census: 41 Findings include: a) Resident #43 Closed record review revealed Resident #43 was an [AGE] year old woman who was admitted to the facility on [DATE]. She was transferred to the Behavioral Health Unit at a local hospital for evaluation on 06/26/11, and was subsequently discharged permanently from the nursing home on 07/11/11. - An annual minimum data set Assessment (MDS), with an assessment reference date (ARD) of 04/03/11 for Resident #43 was reviewed at 4:00 p.m. on 08/03/11. This assessment documented that, during the 7-day lookback period ending on 04/03/11, Resident #43 was able to make herself understood and clearly understood others. She was documented as having no physical behavioral symptoms but as having verbal behavioral symptoms directed toward others on one (1) to three (3) days during the 7-day lookback period. The facility documented that the resident's behaviors did not have any impact on her or on others. The facility documented that Resident #43 exhibited wandering behavior four (4) to six (6) days during the 7-day lookback period, but that these behaviors did not put her at significant risk of getting to a potentially dangerous place, nor did the wandering intrude on the privacy or activities of others. - Based upon the MDS of 04/03/11, an interdisciplinary care plan was developed, and a meeting was conducted with the interdisciplinary team and the resident's son and medical power of attorney (MPOA) on 04/06/11. This care plan, when reviewed at 4:15 p.m. on 08/03/11, included problems / strengths to be addressed in the following areas: Compromised short term memory, persistent episodes of anger manifested by her thinking that she do… | 2014-12-01 |
| 10780 | 10780 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 157 | D | 1 | 0 | MZQB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, and staff interview, the facility failed to immediately and fully inform the physician of significant findings associated with the health status of two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. Upon leaving the orthopedist's office on [DATE], the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was made "do not resuscitate" by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a regi… | 2014-12-01 |
| 10781 | 10781 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-08-25 | 157 | D | 1 | 0 | 1HRH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, and staff interview, the facility failed to immediately and fully inform the physician of significant findings associated with the health status of two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. Upon leaving the orthopedist's office on [DATE], the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was made "do not resuscitate" by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a regi… | 2014-12-01 |
| 10782 | 10782 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2011-08-31 | 504 | D | 1 | 0 | ZR0U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain laboratory services in accordance with physician orders [REDACTED]. Resident identifier: #70. Facility census: 82. Findings include: a) Resident #70 Review of Resident #70's medical record, conducted on 08/30/11 and 08/31/11, revealed this [AGE] year old female had the following Diagnoses: [REDACTED]. Review of the resident's physician orders [REDACTED]." Review of the medical record found no evidence the UA and C&S were completed as ordered. On 08/31/11 at approximately 12:30 p.m., interview with the director of nursing (DON - Employee #102) confirmed the facility did not complete the UA and C&S. The DON stated the facility had approximately five (5) nurses who worked to try and get a urine specimen from the resident, but they had difficulty because of her incontinence. She went on to say they attempted to use the method of straight catheterization to obtain the urine sample, but this did not work either as they ran into difficulty and could not complete the procedure. On 08/31/11 at approximately 4:00 p.m., the DON informed this surveyor that the resident's physician knew the facility did not obtain the UA and C&S, but he did not order anything additional due to the order he had written for [MEDICATION NAME] (antibiotic) 500 mg. Subsequent review of the medical record found no evidence to reflect staff made the physician aware of their inability to obtain a urine specimen for the UA and C&S. | 2014-12-01 |
| 10783 | 10783 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2011-08-02 | 154 | D | 1 | 0 | H4MU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, physician interview, and family interview, the facility failed to ensure the responsible party of one (1) of five (5) sampled residents, who lacked capacity to understand and make informed healthcare decisions, was informed in advance about a change in care that may affect the resident's well-being. The facility did not receive approval from Resident #72's health care surrogate (HCS) before discontinuing the resident's medication, labs and diagnostic tests, and weights. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident weighed 88 pounds (#) on admission, and his current weight on 08/02/11 was 98#. -- On 06/23/11, a physician's orders [REDACTED]. Resident refusal." -- An interview with the social worker, on 08/02/11 at 11:35 a.m., revealed the social worker had no knowledge of the resident not receiving his medication, labs and diagnostic tests, and weights. She was not aware that the resident was refusing to take his medication and was refusing to be weighed. She also stated, "I was unaware that the HCS was not returning the calls to the nursing staff about his (the resident's) refusal to take his medication and refusing to be weighed." -- An interview with the director of nursing (DON), on 08/02/11 at 10:00 a.m., revealed the resident was refusing to take his medication and refusing to be weighed. She stated, "The HCS was notified multiple times and did not return the calls." She further stated, "When a resident is refusing to take their medication and refusing to be weighed, it is my practice to have the physician discontinue the medication and weights." -- An interview with the physician, on 08/02/11 at 2:00 p.m., revealed the physician was unaware that the resident's HCS was not informed of the medications and the weights discontinued. She s… | 2014-12-01 |
| 10784 | 10784 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2011-08-02 | 250 | D | 1 | 0 | H4MU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility did not provide medically-related social services to one (1) of five (5) sampled residents. Resident #72 lacked the capacity to understand and make informed healthcare decisions. The facility discontinued all of his medications, labs and diagnostic tests, and his weights without having approval from the resident's health care surrogate (HCS). Nursing staff attempted to notify the HCS before discontinuing the medication and weights, and the HCS did not respond to the telephone notifications. The nursing staff notified the physician, who gave orders to discontinue the medications and weights. The social services director, who was unaware of the resident's refusals and unaware that the HCS had failed to respond to notification attempts by the facility, did not ensure the resident had representation from an HCS who was acting in accordance with the resident's known wishes or, if these were not known, his best interests. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident weighed 88 pounds (#) on admission, and his current weight on 08/02/11 was 98#. -- On 06/23/11, a physician's orders [REDACTED]. Resident refusal." -- An interview with the social worker, on 08/02/11 at 11:35 a.m., revealed the social worker had no knowledge of the resident not receiving his medication, labs and diagnostic tests, and weights. She was not aware that the resident was refusing to take his medication and was refusing to be weighed. She also stated, "I was unaware that the HCS was not returning the calls to the nursing staff about his (the resident's) refusal to take his medication and refusing to be weighed." -- A review of social service notes for June 2011 found no acknowledgement of awareness that the HCS was not responding to calls f… | 2014-12-01 |
| 10785 | 10785 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2011-08-02 | 360 | D | 1 | 0 | H4MU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide a nourishing diet that meets the daily nutritional and special dietary needs of one (1) of five (5) sampled residents. Record review revealed Resident #72 weighed 88 pounds (#) on admission and now weighed 98#. The resident's ideal body weight range was 145# to 165#, and the resident was not ordered an enhanced diet to promote weight gain. Resident identifier: #72. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident's weight fluctuated from 88.2 pounds (#) on admission to 102#. The resident's weight on 08/02/11 was 98#. An interview with the registered dietitian (RD - Employee #129), on 08/02/11 at 11:00 a.m., revealed the RD did not understand why the resident was not receiving enhanced foods related to his weight loss. She stated, "He should have received the enhanced food with the diet orders on admission." She stated, "I will give the resident enhanced food on his diet." An interview with the dietary manager (Employee #11), on the morning of 08/02/11, revealed the resident did not have an enhanced diet related to the amount of snacks in his room. The dietary manager reported the family brought in snacks, crackers, peanut butter, and candy and that was what he ate all of the time. She felt that, with the amount of snacks in the resident's room, he did not need an enhanced diet. A review of the resident's care plan on admission revealed the following: Focus: "Potential for nutritional impairment r/t (related to) prior history of malnutrition and less than 50% of food consumed and history of GERD." Goals: "Will consume / tolerate 50% of meals and 75%-100% of fluids provided daily through next review." Interventions: "Encourage and assist as needed to consume mechanical soft diet. Administer [MEDICATION NAME] per … | 2014-12-01 |
| 10786 | 10786 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2011-08-05 | 157 | D | 1 | 0 | PBEB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the responsible party and/or physician, for one (1) of seven (7) sampled residents, when acute changes in condition occurred, and failed to notify the responsible party when changes were made in medication and treatment orders as a result of this acute changes in condition. Resident #14 developed a "blister" on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. There was no evidence the family was informed of the "blister" or the topical antibiotic that was ordered on [DATE] to treat this area. On 05/19/11, the resident's family member brought to a nurse's attention that his left great toe was red and painful to touch, the left foot was warm to touch, and red streaking was present up to the resident's ankle. On the evening of 05/19/11, the physician ordered a 10-day course of oral antibiotics (Keflex) to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). There was a lack of evidence to reflect the family had been notified of this new medication or the reason for its use. When the presence of yellow drainage was identified in a nursing note signed by the author on 05/22/11, there was no evidence to reflect the nursing staff notified the physician or the family of this new finding. The tip of the toe was noted to be "blackish / brownish" in color on 05/26/11, after which the physician discontinued the topical antibiotic to the toe (and ordered the application of skin prep) and discontinued the Keflex for the infection to the toe (and ordered [MEDICATION NAME] for a new upper respiratory infection). There was no evidence to reflect nursing staff notified the resident's family of the change in the status of the resident ' s great toe or of the discontinuation of both the oral and t… | 2014-12-01 |
| 10787 | 10787 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2011-08-05 | 225 | D | 1 | 0 | PBEB12 | . Based on a review of grievance / complaints received by the facility since 09/24/11 and staff interview, the facility failed to immediately report allegations of abuse and neglect to all State officials in accordance with State law for two (2) of six (6) sampled residents. The medical power of attorney representative (MPOA) for Resident #7 reported to staff, on 09/28/11, various concerns including Resident #7 not getting enough to eat and not receiving her snacks, not receiving enough fluids, and her hair was not being combed. This grievance contained allegations of neglect that were not immediately reported to State officials. The MPOA of Resident #8 reported to staff, on 10/31/11, various concerns including that staff did not pay attention to Resident #8, staff was not bringing the resident out of her room, that a nursing assistant told the resident she should be in bed asleep, and that her chair alarm was unplugged. These allegations of neglect were not immediately reported to State officials in accordance with State law. Resident identifiers: #7 and #8. Facility census: 57. Findings include: a) Resident #7 Review of the resident grievance / complaint forms received by the facility since 09/24/11 found the following concerns expressed by the MPOA of Resident #7, as recorded on the form by the director of nursing (DON) on 09/28/11, in the section with the heading "Describe the nature of the grievance / complaint (be specific). ..." (quoted as written): "Concerned not getting enough to eat and not receiving her snacks. Had episode of unresponsiveness a couple of weeks ago and was concerned she was dehydrated." On the associated resident grievance / complaint investigation form dated 09/28/11, the DON recorded the following in the section with the heading "Describe the incident as provided by the resident / individual" (quoted as written): "Concerned resident was not receiving enough fluids. B/P (blood pressure) was low and had incident of unresponsiveness. Concerned snacks are not being given and resident's ha… | 2014-12-01 |
| 10788 | 10788 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2011-08-05 | 224 | G | 1 | 0 | PBEB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to assess / monitor and obtain timely medical intervention for one (1) of seven (7) sampled residents, resulting in a delay in identification and treatment of [REDACTED]. Resident #14 developed a blister on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. The facility did not obtain an order to continue the application of this topical antibiotic to the toe until 05/14/11, and there was no evidence the family was informed of the blister or the topical antibiotic ordered to treat this area. There was no evidence to reflect the nursing staff routinely assessed / monitored the status of this blister after the daily application of a topical antibiotic and a dressing were ordered on [DATE], as evidence by a lack of any nursing progress notes from 04/22/11 until 05/19/11. On 05/19/11, the resident's family member brought to a nurse's attention that his left great toe was red and painful to touch, the left foot was warm to touch, and red streaking was present up to the resident's ankle; however, receipt of the order for a topical antibiotic received on 05/14/11 and an acknowledgement of the family's concerns about the resident's left foot were not recorded in any nursing progress notes until a late entry was made on 07/08/11. On the evening of 05/19/11, the physician ordered a 10-day course of oral antibiotics (Keflex) to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose of Keflex was not administered until 6:00 a.m. on 05/20/11, and the 6:00 p.m. dose on 05/26/11 was skipped due "awaiting delivery from pharmacy". After the Keflex was started, there remained a lack of evidence to reflect that nursing staff was rou… | 2014-12-01 |
| 10789 | 10789 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2011-08-05 | 425 | D | 1 | 0 | PBEB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to ensure an antibiotic was available for administration in accordance with physician orders [REDACTED]. On the afternoon of 06/13/11, a 7-day course of Keflex was ordered at the family's request to treat gangrene to the left great toe, which was to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose was not administered until 12:00 p.m. on 06/14/11, with the first three (3) doses having been skipped due to "awaiting delivery from pharmacy". When the first three (3) scheduled doses of the medication were not available for administration, the facility also failed to adjust the stop date for this antibiotic to ensure all twenty-eight (28) doses were administered. As a result, the resident only received twenty-five (25) doses. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. A review of the resident's physician orders [REDACTED]. Nurses' initials on the MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]"awaiting delivery from pharmacy"). No reason was documented for the skipped dose due at 12:00 a.m. on 06/14/11. When the first three (3) scheduled doses of the medication were not available for administration, the facility failed to adjust the stop date for this antibiotic to ensure all twenty-eight (28) doses were administered. As a result, the resident only received twenty-five (25) doses. The order was discontinued at 4:00 p.m. on 06/20/11, although the resident did not receive all scheduled doses for this course of antibiotics. (See also citation at F224.) . | 2014-12-01 |
| 10790 | 10790 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2011-08-05 | 514 | E | 1 | 0 | PBEB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed, for one (1) of seven (7) sampled residents, to maintain clinical records in accordance with accepted professional standards and practices that ensure each resident's record is complete and accurately documented. The extent of the deficient practice affecting Resident #14 demonstrated a pattern of non-compliance with this requirement. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. Record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a blister on the left great toe, to which the podiatrist applied [MEDICATION NAME]; the podiatrist also recorded the need for follow-up by the facility's physician. ([MEDICATION NAME] is a topical antibiotic.) -- 2. Lack of documentation related to an acute change in condition and change in treatment There were no entries from 05/12/11 through 05/19/11, during which time: - On 05/12/11, the podiatrist identified and treated a blister to the left great toe and recommended follow-up treatment by the facility's physician; - On 05/14/11, the attending physician ordered daily applications of [MEDICATION NAME] (a topical antibiotic) and a dry dressing to the left great toe; and - On 05/19/11, the attending physician ordered Keflex (an oral antibiotic) four-times-daily for "possible infection / [MEDICAL CONDITION]" of the left great toe. There was no contemporaneous entry in the nursing progress notes to correspond with receipt of an order for [REDACTED]. There was no contemporaneous entry in the nursing progress notes to correspond with receipt of a verbal order for Keflex to on the evening of 05/19/11, and there was no ent… | 2014-12-01 |
| 10791 | 10791 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2011-08-05 | 280 | D | 1 | 0 | PBEB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to review and revise the care plan of one (1) of seven (7) sampled residents who experienced an acute change in condition with resultant changes in treatment. Resident #14 developed a blister on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. On 05/14/11, the attending physician ordered the application of a topical antibiotic and a dressing to the resident's left great toe, but no episodic care plan was developed to address this. On 05/19/11, the attending physician ordered an oral antibiotic (Keflex) four-times-daily to treat "possible infection / [MEDICAL CONDITION]" of the left great toe and foot. An episodic care plan was developed to address an infection to the left great on 05/20/11; this care plan had a discontinuation date of 05/27/11. The resident subsequently developed gangrene (which was diagnosed on [DATE]), and the facility failed to review and revise his care plan to address the deterioration in the status of the resident's toe until 06/14/11, by which time the family asked that he be placed on comfort measures only. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. Further record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a blister on the left great toe, to which the podiatrist applied [MEDICATION NAME]; the podiatrist also recorded the need for follow-up by the facility's physician. A box located at the bottom of the form contained a checkmark next to the following statement (quoted as typed): "Based on review of history medical records and exam; this pt (patient) is at medical risk of significant complications and medical care is … | 2014-12-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );