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174 rows where "filedate" is on date 2015-08-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9819 | 9819 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 225 | E | 1 | 0 | L6DT11 | . Based on review of the facility's concern/complaint files, review of the reportable allegations in the facility's abuse/neglect files, and staff interviews, the facility failed to ensure all allegations of neglect and abuse were reported and/or investigated. Additionally, the facility failed to report the results of an investigation of an allegation of neglect within five (5) working days of an incident. The unreported allegations included: soiled clothing, bed linens, and furnishings, failure to provide mouth care, failure to provide a breathing treatment, bruising of unknown origin, failure to answer call lights, staff eating a resident's food, and failure to provide pain medication. The follow-up which was not reported was a complaint related to a failure to check blood sugar levels. Resident identifiers: #119, #5, #71, #116, #117, and #60. Facility census: 115. Findings include: a) Resident #119 The social worker (Employee #9) provided the past three (3) months of reportable allegations of abuse/neglect on 04/02/12, at approximately 11:00 a.m. The reportable allegations revealed an allegation involving Resident #119 which was reported on 12/27/11. The family's concern was regarding the facility's failure to check blood sugar levels. The facility did not have a five (5) day follow up which summarized the results of the investigation of this allegation of neglect. . . b) Resident #5 Review of complaint files revealed a complaint, dated 02/23/12, in which Resident #5's family alleged the resident vomited on 02/22/12 at 6 p.m., and still had vomit on her shirt and handrail on 02/23/12 at 10:45 a.m. The family also stated the resident had not received mouth care. The facility failed to report this allegation. During an interview with Employee #9 on 04/03/12, at approximately 3:45 p.m., she stated, "The last director of nursing took care of this, and I can find no other information on it." c) Resident #60 Within the complaint files was a complaint, dated 01/26/12, regarding this resident. A staff member from the … | 2015-08-01 |
| 9820 | 9820 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 243 | E | 1 | 0 | L6DT11 | . Based on review of family council meeting minutes, resident council meeting minutes, and staff interview, the facility failed to act upon the issues identified by the family council and the resident council. There was no evidence the concerns brought to the attention of the facility, by either group, were seriously considered and/or addressed. This practice had the potential to affect more than an isolated number of residents. Facility census 115. Findings include: a) Resident Council On 01/04/12, the resident council completed a grievance report stating scheduling was inappropriate. The facility's resolution to the concern was, "We schedule staff to census and state requirements of 2.25. Facility attempts to replace call-ins immediately. Running ads for new hires. Offering vacant shifts for bonus." The complaint was made by the resident council on 01/04/12, but was not addressed to the resident council on 02/14/12. b) Family Council Review of the minutes of a family council meeting, held on 03/20/12, revealed family members made various complaints: - Residents were not gotten out of bed - The facility's staffing level was inadequate - Resident rooms were not clean - Water and ice was not passed - Water and ice was out of residents' reach - Water was not given to those who needed help drinking - Incontinent residents were not changed in a timely manner - Call lights were not answered in a timely manner - Staff members passed call lights and did not answer them "stating not their residents." - Lotion was not applied to residents - Residents were not being walked - Medications were passed late - Catheter bags were hung incorrectly There was no evidence the facility gave serious consideration to any of the concerns expressed by the members of the family council. There was nothing to suggest the facility acted upon, or made any attempts to investigate the concerns expressed by the family council. Had the facility listened to the concerns, evaluated the concerns, and/or sought additional information, some of the con… | 2015-08-01 |
| 9821 | 9821 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 272 | D | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, facility policy review, and staff interview, the facility failed to ensure a stage I pressure ulcer was assessed for one (1) of four (4) residents. The resident developed a stage I pressure ulcer which was not assessed according to the facility's policy on wound management. Resident identifier: #84. Facility census: 115. Findings include: a) Resident #84 On 04/02/12, review of the medical record for Resident #84 revealed an [AGE] year old paraplegic male. According to the medical record, he developed a stage I pressure ulcer on 03/20/12. The wound, measuring 3.5 cm in width, was identified by a local surgeon to whom the facility referred the resident due to multiple vascular ulcers to the bilateral lower extremities. The surgeon ordered a derma float air mattress, on 03/21/12, to promote wound healing. The order, dated 03/21/12, stated, "(physician name) ordered HILL ROM AIR MATTRESS FOR STAGE I ULCERS ON BUTTOCKS." The facility provided the resident with the air mattress. The assistant director of nursing (Employee #65) provided a copy of the facility's wound management policy on 04/03/12 at 9:40 a.m. The policy, dated January 2008, stated "Weekly Wound Rounds: The team makes rounds weekly to evaluate wound treatment and other care interventions. The licensed nurse evaluates the pressure ulcer and documents pressure ulcer healing using the pressure ulcer documentation form. If a pressure ulcer fails to show progress toward healing within 2-4 weeks the team reevaluates the treatment plan to determine whether to modify the current interventions. Individual nurses should not alter the treatment plan without input from the interdisciplinary team and the physician." The medical record contained non pressure and skin condition reporting forms for non pressure related areas on the resident's coccyx. As of 04/03/12, the last documentation on this form was dated 03/07/12. At that time the area on the coccyx was red, … | 2015-08-01 |
| 9822 | 9822 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 279 | D | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, care plan review, and staff interview, the facility failed to ensure two (2) of four (4) resident's care plans were updated to reflect the development of pressure ulcers. Resident identifiers: #30 and #84. Facility census: 115. Findings include: a) Resident #84 On 04/02/12, review of the medical record for Resident #84 revealed an [AGE] year old paraplegic male. According to the medical record, he developed a stage I pressure ulcer on 03/20/12. The wound, measuring 3.5 cm in width, was identified by a local surgeon to whom the facility referred the resident due to multiple vascular ulcers to the bilateral lower extremities. The care plan review occurred on 04/03/12. This review revealed the facility had not addressed the development of the stage I pressure ulcer. The director of nursing (Employee #46) was informed that the facility had not included this issue in the resident's care plan on 04/03/12 at approximately 9:30 a.m. On 04/04/12, at approximately 4:00 p.m., the minimum data set registered nurse (Employee #39) confirmed the resident's peripheral vascular ulcers were care planned, but the stage I pressure ulcer on the coccyx was not addressed in the care plan. . . b) Resident #30 Review of the facility's treatment administration record found this resident had stage II pressure ulcer wounds to her bilateral heels. Further investigation found the facility did not have a care plan regarding the provision of care and treatment of [REDACTED]. On 04/03/12, at approximately 12:45 p.m., Employee #65, the assistant director of nursing, confirmed the facility failed to develop a care plan for the wounds. . | 2015-08-01 |
| 9823 | 9823 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 309 | E | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of grievances/complaints, and staff interview, the facility failed to provide or arrange for care and services for two (2) of twelve (12) sample residents. One (1) resident was not scheduled for a follow-up appointment with a physician. The other resident was not provided physician ordered treatments. Resident identifiers: #13 and #15. Facility census: 115. Findings include: a) Resident #13 Resident #13 was admitted to the facility on [DATE], after right total knee arthroplasty. She had thirty (30) staples in her right knee. Review of the discharge summary from the hospital revealed she was to return to her physician in two (2) weeks for removal of the staples. Two (2) weeks would have been 03/23/12. Review of the facility's grievances/complaints found Resident #13's daughter made a complaint on 03/26/12 because the facility did not schedule the resident's follow up appointment. Interview with Employee #9, the social worker, on 04/03/12 at 1:45 p.m., revealed the facility failed to schedule the appointment until after the family member made the complaint. . . b) Resident #15 On 04/04/12, at approximately 9:30 a.m., medical record review for Resident #15 revealed the following physician's orders [REDACTED]. toe with wound cleanser and saline, apply [MEDICATION NAME] cream, cover with 4x4 and wrap with kling and ace bandage everyday, dayshift - Day Shift everyday r/t (related to) gangrenous ulcer to left great toe." The treatment administration record for March 2012, reviewed on 04/04/12, at approximately 9:45 a.m., revealed the treatments were not performed to Resident #15's left great toe or right great toe on 03/17/12. The treatment administration record also revealed another ordered treatment, "Clean right buttocks with soap and water apply skin protectant cream qs (every shift) and prn (as needed) Start Date: 2/9/2012 Night Shift, Day Shift, Everyday," was not performed on 03/17/12. On 04/04/12, at … | 2015-08-01 |
| 9824 | 9824 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 353 | E | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record reviews, staff interviews, review of the staffing worksheet, grievance/concerns files, and staff payroll information, the facility failed to provide sufficient staffing to ensure optimum care and services for the residents. Residents did not receive scheduled showers, meals were not served on time, treatments were not completed as ordered, and skin assessments were not completed as ordered. This practice affected twenty-three (23) of one hundred fifteen (115) residents, and had the potential to affect the care and well-being of all residents who required any of the aforementioned services from facility nursing personnel. Resident identifiers: #3, #6, #8, #15, #17, #29, #30, #39, #41, #42, #48, #50, #52, #58, #64, #65, #76, #80, #83, #85, #94, #97, and #98. Facility census: 115. Findings include: a) Residents #3, #8, #17, #29, #39, #52, #58, #76, #85, #94, #97, and #98 Review of the facility's shower schedule and care plans identified residents were to receive showers twice a week. According to the facility's functional performance record, these residents did not receive their regularly scheduled showers as ordered during the month of March 2012. -- Resident #17 received one (1) shower -- Resident #52 received three (3) showers -- Resident #3 received one (1) shower -- Resident #58 received no showers -- Resident #76 received no showers -- Resident #8 received two (2) showers -- Resident #39 received one (1) shower -- Resident #85 received four (4) showers -- Resident #94 received four (4) showers -- Resident #97 received two (2) showers -- Resident #98 received one (1) shower -- Resident #29 received three (3) showers During confidential interviews with nursing staff members, it was stated, "When there are only two (2) nursing assistants scheduled on the hall it is impossible to do showers, we only have time to keep them dry and wash their hands and face." On 04/03/12, at approximately 1:00 p.m., Employee #46, t… | 2015-08-01 |
| 9825 | 9825 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 465 | D | 1 | 0 | L6DT11 | . Based on observation and staff interview, the facility failed to maintain a safe, clean and homelike environment. Resident rooms were found to have squashed food, trash, soiled gloves, and soiled clothing on the floor. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 115. Findings include: a) During tour of the facility, on 04/02/12, at approximately 09:15 a.m., room 121 was found littered with straw papers and plastic wrappers. Squashed grapes were found on the floor also. Review of the dietary menu for the breakfast meal found grapes were not served on 04/02/12. b) In room 119, on the morning of 04/02/12, a soiled gown was found on the floor in the corner of the room. c) Room 120 had four (4) pairs of soiled gloves on the floor beside the trash can and used dirty bath towels were on the bathroom floor. Review of the facility's grievance reports found families had complained to the facility, on 03/20/12, of rooms not being clean. These findings were addressed with Employee #46, the director of nursing, on 04/03/12, at approximately 10:45 a.m. She stated, "We do not have housekeeping services after 3:30 p.m." . | 2015-08-01 |
| 9826 | 9826 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 507 | D | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure laboratory results were available for clinical management for one (1) of four (4) residents. On 04/03/12, the resident's medical record did not contain the results of a laboratory test that was performed on 03/09/12. Resident identifier: #98. Facility census: 115. Findings include: a) Resident #98 On 04/03/12, at approximately 1:00 p.m., medical record review for Resident #98 revealed a physician's orders [REDACTED]. The test was completed on 03/09/12. Further review of the medical record revealed the results of the test were not in the record. Employee #68 (licensed practical nurse) looked through the facility's laboratory book and could not locate the results. The director of nursing (Employee #46) provided a copy of the test results on 04/03/12, at approximately 3:00 p.m. By not having the results of the test on the resident's clinical record, the facility could not ensure this information was available if needed for clinical management of the resident. . | 2015-08-01 |
| 9827 | 9827 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-06-15 | 225 | D | 1 | 0 | TK0311 | . Based on record review, review of the facility's abuse and neglect reporting and investigation files, and staff interviews, the facility failed to report and investigate an allegation of abuse. Resident #21 reported to her husband a nurse had been unnecessarily rough pushing in her catheter. There was no evidence the facility reported or investigated this incident as an allegation of abuse. This was true for one (1) of nine (9) sampled residents. Resident identifier: #21. Facility Census: 168. Findings include: a) Resident #21 Record review found it was recorded, on 02/26/12 at 7:00 a.m., "Resident catheter came out with balloon intact bled a little cleanse skin with skin integrity put another catheter in. Resident complain of pain and discomfort pain med given. Resident called husband that nurse was being unnecessarily rough pushing the cath (catheter) in. Explained the procedure to the husband. " A review of the facility's abuse and neglect reporting and investigation files revealed this had not been investigated or reported to the appropriate State agency. This was brought to the attention of the assistant director of nursing (Employee #73) on 06/15/12 at 10:00 a.m. She verified the facility had not reported or investigated this incident. This incident was discussed with the Administrator at 11:00 a.m. on 06/15/12. She did not feel this note had been an allegation of abuse that needed to be reported and investigated. . | 2015-08-01 |
| 9828 | 9828 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-06-15 | 514 | D | 1 | 0 | TK0311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure medical records contained complete and accurate information, to include the services provided to residents and the names of those who documented care for residents. The facility failed to ensure pertinent issues associated with the care and treatment for [REDACTED]. Resident #21's medical record contained a nursing note that was not signed. The medical records did not contain complete information for two (2) of nine (9) sampled residents. Resident identifier: #167 and #21. Facility census: 168. Findings include: a) Resident #167 1) Review of the medical record for Resident #167, found it was recorded in the nursing notes, on 04/13/12 at 10:00 a.m., this resident had a temperature of 100.3. The nursing note stated "Tylenol given". The medication administration record (MAR) for 04/13/12 was reviewed. The MAR did not reflect this resident received Tylenol at the time identified in the nursing entry. This was brought to the attention of Employee #73. She verified there was no Tylenol recorded on the MAR for 04/13/12. 2) During a review of the treatment records for Resident #167, it was noted in March 2012, on the medication administration record (MAR), there were instructions to change the PICC (peripherally inserted central catheter) line dressing q (every) week and PRN (as needed). The nurse initialed this on 03/07/12 and on 03/08/12. He then circled his initials. There was no evidence to indicate why his initials had been circled. Employee #80 was interviewed on 06/13/12 at 3:30 p.m. He verified that when you circled your initials, you should turn the record over and record on the back why you placed the circles around your initials. He stated he knew he had changed the dressing, but did not remember why he had placed the circles around his initials. 3) A review of the treatment record for Resident #167 revealed treatments had been completed on the 3:00 p.m. - 11:00 p.… | 2015-08-01 |
| 9829 | 9829 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2012-05-24 | 157 | D | 1 | 0 | 4S5211 | . Based on review of review of medical records and staff interviews, the facility failed to immediately notify the attending physician and the family when there was a significant change in heath status. This affected one (1) of ten (10) sampled residents whose health status required physician intervention and hospitalization . Resident identifier: #105. Facility census: 103 Findings include: a) Resident #105 Review of this resident's medical record revealed a nurse's note, by Employee #115, a registered nurse, dated 03/04/12 at 2:00 p.m., which described, "Resident c/o (complains of) burning with urination. Will obtain clean catch UA (urinalysis) with resident's next void." -- There was no evidence the physician was notified. At 11:25 a.m. on 03/07/12, the record revealed notes describing an unwitnessed fall in the bathroom by the resident with a 2 inch scratch to the top of his head. The physician was notified and the resident was sent to the emergency room for evaluation. The resident was returned to the facility at 4:30 p.m. At 11:00 p.m. on 03/07/12, the nurse's notes stated: "Resident rested most of evening taking clothes off - throwing empty cups and other items on floor - ". This was the first entry of these behaviors in either the nurses' notes or the social service notes since admission. At 12:45 a.m. on 03/08/12, the notes indicted that the resident "...had emesis X 1." At 11:00 p.m. on 03/09/12, a nurse's note described the resident, "...refused to eat supper...Very hard to wake resident up tonight. Temp (temperature) was taken at 11p 100.5 ax (axillary) - cool wash cloths applied at this time...". On 03/11/12, the nurse's notes described the resident had "difficulty swallowing pills..." At 2:30 p.m. on 03/12/12, Nurse #109 notified the physician the resident had a temperature, was lethargic, and "was still not doing well." Orders were received to stop the antibiotic and obtain urine for testing in the morning. -- The physician was not notified of any of these changes in condition until 2:30 p.m. on 03… | 2015-08-01 |
| 9830 | 9830 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2012-05-24 | 279 | D | 1 | 0 | 4S5211 | . Based on record review and staff interview, the facility failed to initiate an interim care plan for one (1) of ten (10) sampled residents who fell and sustained an injury to his head. A care plan was not established to ensure assessment and monitoring of the resident's well-being during a time in which there was a high potential for a change in condition. Resident identifier: #105. Facility census 103. Findings include: a) Resident #105 Review of this resident's medical record revealed the resident had an unwitnessed fall at 11:25 a.m. on 03/07/12. Nurse's notes described the resident had a 2 inch scratch to the top of his head. The physician was notified and the resident was sent to the emergency room for evaluation. A CAT scan failed to identify any acute injury and the resident was returned to the facility at 4:30 p.m. At 11:00 p.m. on 03/07/12, the nurse's notes stated: "Resident rested most of evening taking clothes off - throwing empty cups and other items on floor - ". This was the first entry of these behaviors in either the nurse's notes or the social service notes since admission. At 12:45 a.m. on 03/08/12, the notes indicated the resident "...had emesis X 1." At 11:00 p.m. on 03/09/12, the resident, "...refused to eat supper.. had 360 cc of H2O....Very hard to wake resident up tonight. Temp (temperature) was taken at 11p 100.5 ax (axillary) - cool wash cloths applied at this time..." At 4:00 p.m. on 03/11/12, a nurse documented the resident had "difficulty swallowing pills..." At 2:30 p.m. on 03/12/12, Nurse #109 notified the physician the resident had a temperature, was lethargic, and "was still not doing well." The resident was on an antibiotic at that time. At 10:30 p.m. on 03/12/12, the notes indicated, "Resident refuse meals...lethargic." At 7:30 p.m. on 03/13/12, the notes indicated, "Resident lethargic - combative..." He was visited by the attending physician and sent to the emergency room at 7:00 p.m. The attending physician's progress notes of 03/13/12 stated, "Unresponsive, Shook him sever… | 2015-08-01 |
| 9831 | 9831 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2012-05-24 | 309 | D | 1 | 0 | 4S5211 | . Based on record review and staff interview, the facility failed to provide care and services to ensure the highest practicable physical well-being for one (1) of ten (10) sampled residents. The resident had a fall and hit his head. The facility failed to assess and monitor the resident for a potential closed head injury. Documentation revealed changes in health status for which the facility did not seek medical intervention in a timely manner. Resident identifier: #105. Facility census 103. Findings include: a) Resident #105 Review of this resident's medical record revealed the resident had an unwitnessed fall at 11:25 a.m. on 03/07/12. Nurse's notes described the resident had a 2 inch scratch to the top of his head. The physician was notified and the resident was sent to the emergency room for evaluation. A CAT scan failed to identify any acute injury and the resident was returned to the facility at 4:30 p.m. At 11:00 p.m. on 03/07/12, the nurse's notes stated: "Resident rested most of evening taking clothes off - throwing empty cups and other items on floor - ". This was the first entry of these behaviors in either the nurses' notes or the social service notes since admission. At 12:45 a.m. on 03/08/12, the notes indicated the resident "...had emesis X 1." At 11:00 p.m. on 03/09/12, the resident, "...refused to eat supper.. had 360 cc of H2O....Very hard to wake resident up tonight. Temp (temperature) was taken at 11p 100.5 ax (axillary) - cool wash cloths applied at this time..." At 4:00 p.m. on 03/11/12, a nurse documented the resident had "difficulty swallowing pills..." At 2:30 p.m. on 03/12/12, Nurse #109 notified the physician the resident had a temperature, was lethargic, and "was still not doing well." The resident was on an antibiotic at that time. At 10:30 p.m. on 03/12/12, a note indicated, "Resident refuse meals...lethargic." At 7:30 p.m. on 03/13/12, the note indicated, "Resident lethargic - combative..." He was visited by the attending physician and sent to the emergency room at 7:00 p.m. The at… | 2015-08-01 |
| 9832 | 9832 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2012-05-24 | 327 | G | 1 | 0 | 4S5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on facility record review, hospital record review, staff interview, and anonymous information received during a complaint investigation, the facility failed to provide adequate amounts of fluid to maintain proper hydration for one (1) of ten (10) sampled residents. The resident experience a change in health status and was subsequently hospitalized . An admitting [DIAGNOSES REDACTED]. Resident identifier: #105. Facility census 103. Findings include: a) Resident #105 A review of the medical record revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He had a Foley catheter placed to facilitate healing of the pressure ulcers. At 4:00 p.m. on 03/03/12, after transferring himself from the wheelchair into bed, Resident #103 complained to nursing that his Foley catheter was hurting him. He had 200 cc of amber urine in his drainage bag. At 9:00 p.m. the nurse's note, written by Nurse #4, stated, "...resident was c/o (complaining of) pain upon exam. It was noted cath (catheter) was clamped - and there was some blood in the cath bag." The physician was notified and the catheter was discontinued at the resident's request. The nurse also noted, "Resident voided X 3 lg amts of cl (large amounts of clear) amber urine since." The nurse's note by Employee #115 (Registered Nurse) stated at 2:00 p.m. on 03/04/12, "Resident c/o burning with urination. Will obtain clean catch UA (urinalysis) with resident's next void." There was no evidence a urine specimen was obtained or sent for testing. The medical record contained no entries for 03/05/12 or 03/06/12. The last nurse's note which contained any reference to intake or output was 03/03/12. There were no further entries in the nurse's notes indicating either intake or output until four (4) days later, on 03/07/12 at 11:00 p.m. Nursing notes, dated 03/07/12 at 11:25 a.m., described the resident had an unwitnessed fall in the bathroom. He sustained a two (2) i… | 2015-08-01 |
| 9833 | 9833 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2012-05-30 | 257 | E | 1 | 0 | TN3K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, monitoring of unit air temperatures, resident interview, review of unit complaint records, and review of unit equipment ordering documents, the unit failed to ensure comfortable and safe temperature levels in resident rooms. The air temperatures were uncomfortably warm for residents. The facility was aware that necessary air conditioning equipment was not operational and replacement parts could not be received and installed quickly, mostly related to the age of the building. The replacement equipment was not ordered until 05/17/12. This practice had the potential to affect more than a minimal number of residents residing on the Extended Care Unit. Unit census: 52. Findings include: a) Observations and interviews When entered on 05/30/12 at 11:00 a.m., a huge fan was noticed on the B hall of the Extended Care Unit. As the tour of the unit continued, several fans were observed in hallways and in resident rooms. Some resident rooms were noted to have two (2) fans. Resident interviews and measurements of air temperatures in some resident rooms was undertaken and completed over the next hour (11:00 a.m. until 12:00 p.m.). Residents on all three (3) halls of the unit voiced concerns with being uncomfortable on occasion in the past several days due to the heat in their rooms. On A hall, Resident #5 was interviewed in her room while in bed. This resident stated she had been uncomfortably hot during the previous weekend and at times "had sweat running off my body". This resident further stated that she had planned just that morning to complain to someone, stating that although it was only May, there had been several uncomfortable days and no air conditioning since she did not know when Resident #29 on B hall was observed (at approximately 11:05 a.m.) sitting in her room with two (2) fans running. This resident stated it had been very hot in her room during the evening hours over the past several days. The Resident stated it was… | 2015-08-01 |
| 9834 | 9834 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-08-02 | 152 | D | 1 | 0 | K6SZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to aenure a resident who was alert and oriented was provided the opportunity to make her own health care decisions. Resident #85 had expressed that she did not want cardiopulmonary resuscitation (CPR) and two days later, her medical power of attorney (MPOA) changed this decision without the legal authority to do so and without evidence the resident was involved in this decision. The resident's family was also permitted to sign her admission paperwork without evidence the resident was involved in her admission or in decisions regarding her care at this facility. This practice was evident for one (1) of nine (9) sampled residents. Resident identifier: #85. Facility Census: 84. Findings include: a) Resident #85 Resident #85 was admitted to the facility on [DATE]. Her advance directives were reviewed and it was determined she had appointed a medical power of attorney on [DATE], just two (2) days prior to her admission to this facility. At the time of this resident's admission, on [DATE], the resident completed a cardiopulmonary resuscitation (CPR) form to express her wishes if she were to suffer a [MEDICAL CONDITION], respiratory arrest, or if death was imminent. She directed the facility withhold CPR and all life saving measures. The resident signed this form along with her representative who she had appointed her MPOA. Review of the medical record found that this resident was examined by the physician on [DATE]. It was recorded in the history and physical that she was alert and oriented times four (x 4). There was no incapacity statement found in the medical record to establish this residtn was not able to make her own medical decision and to activate her medical power of attorney. Further review of the medical record found that on [DATE], the appointed MPOA completed and signed a new CPR form stating "I want CPR". This form did not have the resident's signature on it and was com… | 2015-08-01 |
| 9835 | 9835 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-08-02 | 166 | E | 1 | 0 | K6SZ11 | . Based on confidential resident interviews, confidential family interviews, a review of the facility's grievance reports, review of resident council minutes, and staff interview, the facility failed to actively seek a resolution when complaints and grievances were expressed by residents and families. The grievance reports did not address all of the issues expressed in the statement of concern. There was no evidence the facility followed up with all of the concerns. There were concerns that were not explored further to investigate the reason for the concern or whether there was further investigation that needed to be done to resolve the issues. The resident council minutes contained concerns two (2) months in a row regarding the issue of call lights. There was no evidence the grievances were resolved for eighteen (18) of thirty-seven (37) grievances reviewed. This practice affected fifteen (15) residents who had expressed grievances. Resident identifiers: #53, #20, #6, #60, #17, #70, #73, #59, #52, #55, #89, #46, #87, #66, and #88. Facility Census: 84. Findings include: a) Resident Interviews During confidential interviews with alert and oriented residents, on 07/31/12 through 08/02/12 , it was identified they felt there were often complaints and no one addressed them or let you know what they found out. Three (3) confidential family interviews were conducted on 08/01/12. These families felt the facility did not make efforts to resolve grievances and report the findings back to the grievant. b) Grievance Reports The Social Worker was requested to make copies of the last three (3) months (May, June, and July 2012) grievance reports. The following issues were reviewed in these reports. There was no evidence to indicate that issues in these reports had been resolved or further explored as needed. 1) Resident # 53 A grievance form was completed on 05/29/12 in which the grievant expressed a concern with missing items. There was no evidence this was investigated and no resolution had been recorded on the grievance form… | 2015-08-01 |
| 9836 | 9836 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-08-02 | 241 | E | 1 | 0 | K6SZ11 | . Based on confidential resident interviews, observation, review of resident council minutes, and a review of the facility's concern and grievance reports, the facility failed to treat residents in a dignified manner and to respect their private space. The residents verbalized that call lights were not answered and the staff often walked past their room and no one offered to help. The residents verbalized this made them feel they were being ignored and they did not feel they were being treated with dignity and respect. There were also observations of staff members entering rooms without knocking and asking for permission to enter. Seven (7) of nine (9) sampled residents, and three (3) randomly interviewed residents, expressed concerns. Facility Census: 84. Findings Include: a) Call Lights During confidential interviews with residents, there were ten (10) residents who were interviewed. Each one stated call lights were not answered timely. (These residents did not wish their names revealed, so these interviewees identifications have been kept confidential.) Identified in the confidential interviews, conducted 07/31/12 to 08/02/12, were the following statements: 1) One (1) resident stated she could see the staff standing out in the hall and could hear them talking about personal things and not answering her call light. She stated there had been times she has had to lay wet in urine waiting for someone to help. There were five (5) residents who made statements of it taking a long time to answer lights on evening shift. One resident stated she hated to ask the girls to help her because they worked such long hours that they got really tired. She felt sorry for them. She said they often work double shifts. This resident also commented "They get really short with you and do not speak kindly to you sometimes, and it makes you feel as if you are bothering them." There was one (1) confidential interview with a resident who stated she has waited two (2) hours for someone to come answer her light. She stated that sometimes t… | 2015-08-01 |
| 9837 | 9837 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-08-02 | 253 | E | 1 | 0 | K6SZ11 | . Based on observation and staff interview, the facility failed to provide furniture in good repair and a clean sanitary living environment for residents. The rooms were observed to have cracks in the drywall and wallpaper, boxes were stored on the floor that prevented the floor from being properly cleaned, the floor was dirty and dust was present around the wall on the floor around the baseboard. A strong odor was noted in a resident room and the walls were observed to be in need of paint and repair. There were two (2) bedpans on a bathroom floor that were covered with dust. This practice had the potential to affect more than an isolated number of residents. Facility: 84. Findings Include: a) Room 122 During a tour of the facility, on 08/01/12, Room #122 was entered at 11:00 a.m. The resident was in the bed by the window, asleep. There were boxes stored on the floor and this room had a very strong offensive odor. This room was again entered on 08/02/12 at 10:00 a.m. There were still three (3) boxes stacked on floor and the odor was still present in the room. This room was a semi-private room with two (2) people. b) Room 103 During a tour of the facility, on 07/31/12, room #103 was observed to have cracks above the heater and air conditioner and around the hand sink and the hand sanitizer. The floor was observed to be dirty with dust around the baseboards. On 08/02/12 at 10:00 a.m., this room was observed again in greater detail. It was still dirty and dusty around the baseboard, and the bathroom had two (2) bedpans sitting on the floor covered with dust. These bedpans were sitting in the floor in the corner of the bathroom. c) Room 128 Observation of this room revealed the walls by the resident's bed were in need of repair and paint. d) Room 133 The bedside table next to the bed on the left hand side of the room, close to the window, had broken drawers with clothes hanging out the front of the drawers. The front was broken off and hanging there with the clothes coming out around it. The Director of Nursing was m… | 2015-08-01 |
| 9838 | 9838 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-08-02 | 279 | D | 1 | 0 | K6SZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, and staff interview, the facility failed to establish a care plan to address the toileting needs for Resident #46. There was no evidence the direct care staff had been made aware of the toileting needs, nor had a program been initiated in an attempt to prevent this resident from having episodes of incontinence. The goals and intervention for the resident's toileting needs did not correlate with the problem. This was found for one (1) of nine (9) sampled residents. Resident identifier: #46. Facility Census: 84. Findings include: a) Resident #46 During a review of the medical record, it was noted the admission minimum data set (MDS), dated [DATE], identified this resident was frequently incontinent of bowel and bladder. This was the resident's most recent comprehensive assessment. The care area assessment (CAA) for her bladder functioning stated that this resident required assistance with toileting and that this would be included in her care plan. The resident's care plan was reviewed. There was no evidence her plan of care had focused on interventions to improve her bladder functioning. The problem statement was "alteration in elimination of bowel and bladder Functional Incontinence". The goal for this problem contained three (3) parts. The goals were for the resident to be free of UTI (urinary tract infection) through the review period, to maintain the current level of bowel continence through this review, and to have a soft formed bowel movement at least every three days. There was no goal established to decrease the episodes of urinary incontinence. The interventions for this resident's care plan stated to assist her to the toilet and encourage her to hold off voiding as long as possible to help gradually increase her bladder capacity. There was no evidence it had been identified that her bladder capacity was decreased or that the physician had ordered this intervention. When the caregivers were… | 2015-08-01 |
| 9839 | 9839 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-08-02 | 315 | D | 1 | 0 | K6SZ11 | . Based on record review and staff interview, the facility failed to ensure a resident received the necessary services to restore normal bladder functioning. Resident #46 was frequently incontinent when she entered the nursing home after being in the hospital. The facility did not attempt a bladder program to restore her bladder functioning and did not communicate the resident's needs to the care givers so that a plan could be consistently implement. The resident's episodes of incontinence had not been evaluated and used to develop an accurate and effective toileting program to restore as munch normal functioning as possible. This was true for one (1) of nine (9) sampled residents. Resident identifier: #46. Facility Census: #84. Findings include: a) Resident #46 This resident's minimum data set (MDS) assessment, dated 05/31/12, indicated this resident was frequently incontinent of both bowel and bladder. Further review of the care area assessment (CAA) notes found the resident's issue with incontinence was related to her need for assistance. Staff were to be made aware to ensure assistance was provided. Her plan was written "to avoid complications". There was nothing written in the care plan addressing how to decrease incontinence. There was no evidence that a toileting plan had been initiated for this resident in accordance with her minimum data set (MDS) assessment. Her initial care plan focused on her bowel incontinence and there were no goals to improve her bladder functioning. During an interview, on 08/02/12 at 3:00 p.m., nursing assistant (Employee #79), was questioned about this resident's toileting program. She stated this resident was always continent when she took care of her and had never been incontinent. She was ask about the resident's toileting needs and stated that she was toileted after meals and at bedtime and at the 3rd (third) round on night shift. She stated this resident could tell you when she had to go and turned on her light. She said "You just have to go assist her." The resident's toil… | 2015-08-01 |
| 9840 | 9840 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 225 | D | 0 | 1 | KU9T11 | . Based on a review of the abuse/neglect reportable allegations and staff interview, the facility did not ensure allegations of abuse/neglect were reported to licensing boards as required by State law. One (1) of five (5) allegations of abuse/neglect involved the termination of a licensed practical nurse (LPN). The facility did not report this allegation and outcome of the investigation to the LPN board. Resident identifier: #110. Facility census: 92. Findings include: a) Resident #110 On 04/10/13 at 2:04 p.m., the social worker (Employee #56) provided a binder containing the abuse/neglect reportable allegations. After reviewing five (5) allegations it was determined, the facility had not reported one (1) allegation of abuse to the LPN board. According to the reports, on 01/14/13 the facility investigated an allegation of abuse involving alleged victim, Resident #110, and alleged perpetrator, an LPN, Employee #101. The allegation stated, "Reported by another employee that this LPN told Resident to go ask an agitated resident what was wrong." The agitated Resident then threw water on (Resident #110). The outcome/results of the investigation included, "(Resident #110) did have water thrown on him by co -resident. The corrective action by the facility was, "Employee was suspended pending investigation. Employee being terminated related to steps in progressive disciplinary action." During an interview on 04/04/13 at 12:30 p.m., the social worker (Employee #56) confirmed the facility had not reported this issue to the LPN board. The abuse/neglect reporting requirements for West Virginia nursing homes and nursing facilities (revised October 2011) requires allegations of abuse, neglect and/or misappropriation of property where the alleged perpetrator is a licensed professional, be reported to the individual's licensing board. . | 2015-08-01 |
| 9841 | 9841 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 241 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to promote dignity and respect during the provision of care for one (1) of thirty-six (36) Stage 2 sample residents. A nurse administered this resident's insulin injection in a hallway near the nurses' station. Resident identifier: #89. Facility census: 92. Findings include: a) Resident #89 During a random observation, on 04/02/13 at 8:45 a.m., Employee #81, a nurse, was observed administering an injection of insulin into the right arm of Resident #89. Both were standing in the hallway near the nurses' station on the East wing. Medical record review, on 04/03/13 at 10:00 a.m., revealed this resident had a [DIAGNOSES REDACTED]. During an interview with Resident #89, on 04/04/13 at 10:00 a.m., she was unable to give any information related to her insulin injections. An interview was conducted with the assistant director of nursing, Employee #49, on 04/10/13 at 10:40 a.m. She said nurses were supposed to administer insulin injections in the resident rooms. She said they were not allowed to give injections in such places as the dining room or hallways, as that would be a dignity issue. During an interview with the administrator, director of nursing, and clinical consultant, Employee #102, on 04/10/13 shortly before noon, the latter acknowledged she witnessed Resident #89 receiving the insulin injection in the hallway on 04/03/13, but she was not close enough to intervene. She and the administrator acknowledged it was not company policy to give injections in public. . | 2015-08-01 |
| 9842 | 9842 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 253 | E | 0 | 1 | KU9T11 | . Based on observation, staff interview, and an anonymous complaint, the facility failed to maintain an environment free of persistent lingering offensive odors in the rooms and hallways near rooms 106, 137, and 138. In addition, the facility failed to ensure maintenance and housekeeping services for two (2) shower/tub rooms, each between two (2) resident rooms. These practices had the potential to affect more than a limited number of residents. Facility census: 92. Findings Include: a) Upon initial tour of the facility, on 04/01/13 at 12:30 p.m., the hallways of the facility were noted to have offensive odors. An anonymous complaint was received by the Office of Health Facility and Licensure (OHFLAC) on 04/06/13, in which the complainant stated the facility had an offensive odor. On each day of the survey, persistent offensive odors were noted in the facility, by all five (5) members of the survey team. This odor was specifically noted in the hallways near, and in, rooms 106, 137, and 138. b) During observation of the facility, on 04/08/13 at 3:30 p.m., the bathtub in the shower/tub room for rooms 135 and 137 was rusty, soiled, and had water dripping from the faucet. The bathtub shared by rooms 136 and 138 was also rusty and soiled. The shower/tub rooms were used to store unrelated items. Each room was in need of housekeeping services. A registered nurse, Employee #17, observed these shower/tub rooms on 04/08/13 at 3:45 p.m. and confirmed the identified maintenance and housekeeping issues. . | 2015-08-01 |
| 9843 | 9843 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 254 | D | 0 | 1 | KU9T11 | . Based on observation and staff interview, the facility failed to ensure residents' bed linens were in good condition. The beds for four (4) of ninety two (92) residents had bed linens that were worn and had holes in them. Resident identifiers: #45, #86, #101, and #109. Facility census: 92. Findings include: a) Residents #45, 86, #101, and #109 On 04/10/13 at 11:00 a.m., an observation of these residents' linens revealed the fitted sheets were worn and had holes in them. On 04/10/13 at 11:15 a.m., during an interview with the executive director (Employee #13) and the clinical services consultant (Employee #102) regarding the condition of the residents' bed linens, neither disagreed the sheets were in poor condition. By the time of exit, no further information was provided regarding the condition of the fitted sheets. . | 2015-08-01 |
| 9844 | 9844 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 278 | D | 0 | 1 | KU9T11 | . Based on a review of the medical record, minimum data set assessment (MDS), and staff interview, the facility did not ensure the MDS assessment for one (1) of thirty six (36) Stage II residents accurately reflected the resident's status. Resident #21's quarterly assessment incorrectly reflected the resident had broken or ill-fitting dentures. The resident did not have dentures. Resident identifier: #21. Facility census: 92. Findings include: a) Resident #21 On 04/08/13 at 2:45 p.m., a review of Resident #21's quarterly MDS assessment, assessment reference date 03/22/13, Section L0200, indicated the resident had loosely or broken fitting full or partial dentures. On 04/08/13 at 3:00 p.m., Employee #75 (registered nurse/assessment coordinator) indicated she looked in the resident's mouth and verified the resident did not wear dentures. She confirmed the MDS assessment, Section L0200, did not correctly reflect the resident's dental status. . | 2015-08-01 |
| 9845 | 9845 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 279 | D | 0 | 1 | KU9T11 | . Based on medical record review and staff interview, the facility failed to develop an accurate comprehensive care plan for two (2) of thirty-six (36) Stage 2 sample residents. Residents #128 and #125 had bladder incontinence which was not addressed in their care plans. Resident identifiers: Residents #128 and #125. Facility census: 92. Findings include: . a) Resident #128 On 04/08/13 at 4:50 p.m., a review of Resident #128's medical record revealed the resident experienced bladder incontinence while at the facility. The minimum data set (MDS) admission assessment, with an assessment reference date (ARD) of 11/28/12, indicated the resident was always incontinent of urine. An MDS 30 day assessment, with an ARD of 12/08/12, indicated the resident was frequently incontinent of urine. An MDS 60 day assessment, with an ARD of 01/28/13, indicated the resident was frequently incontinent of urine. An MDS 90 day assessment, with an ARD of 02/28/13, indicated the resident was always incontinent of urine. The nursing progress notes, dated 02/28/13, indicated the resident was occasionally incontinent of bowel and bladder and sometimes used the bathroom with assistance. The nursing progress notes dated 03/01/13 and 03/05/13 indicated the resident was incontinent of urine and sometimes used the bathroom with assistance. The care area assessment (CAA), completed with the admission assessment on 11/28/12, indicated the facility would care plan the area of urinary incontinence to ensure staff were aware of the resident's toileting/incontinence needs. On 04/08/13 at 5:00 p.m., upon inquiry regarding why Resident #128 had no care plan for incontinence, Employee #75 (registered nurse/assessment coordinator) said the facility had care planned the incontinence/toileting needs for this resident until February 2013, then discontinued this area from the resident's care plan. Employee #75 confirmed the resident remained incontinent and needed assistance with toileting. . . b) Resident #125 Review of a minimum data set (MDS), with an asse… | 2015-08-01 |
| 9846 | 9846 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 323 | D | 0 | 1 | KU9T11 | . Based on observation and staff interview, the facility failed to ensure the residents' environment was as free of accident hazards as possible. A medication was left in a clear plastic cup on a resident's over-the-bed table. Resident identifier: #96. Facility census: 92 Findings include: a) Resident #96 Observation before, during, and after a medication pass with a nurse (Employee #33) on 04/02/13, revealed an unidentified white pill in a clear plastic medication cup on Resident #96's over-the-bed table. This medication was not observed by the nurse prior to surveyor intervention. Employee #33 said it was not a medication she had given the resident. she said it was a medication left from some other medication pass. Employee #33 said she would dispose of the medication, which she believed was a cholesterol lowering drug. This resident resided in a four (4) bed room. In addition, there were ambulatory residents who resided in the facility. During an interview with the administrator, director of nursing, and clinical consultant (Employee #102), on 04/10/13 shortly before noon, no further information was provided. . | 2015-08-01 |
| 9847 | 9847 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 329 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of unnecessary medications for ten (10) residents, and staff interviews, the facility failed to ensure one (1) of ten (10) residents was free from unnecessary medications. The facility did not monitor the use of a medication for clinically significant side effects or consequences as the result of using the medication. The facility did not obtain blood glucose levels as ordered by the physician, for a resident on a prescribed medication known to increase blood glucose levels. Resident #83. Facility census: 92. Findings Include: a) Resident #83 Review of medical records, on 04/09/13 at 10:20 a.m., revealed a physician order [REDACTED]." [MEDICATION NAME] is a medication known to increase blood glucose levels. Further review of medical records revealed the resident's glucose was checked on 10/01/12 at 6:36 a.m., prior to the physician's orders [REDACTED]. No additional blood glucose levels were found in the medical record review. At 10:40 a.m., a registered nurse, Employee #82, stated she was also unable to find the blood glucose level results, as ordered by the physician. At 10:50 a.m., a registered nurse, Employee #33, also stated the blood glucose level was not documented in the e-mar. No evidence was presented to indicate the blood glucose levels were completed as ordered. . | 2015-08-01 |
| 9848 | 9848 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 334 | D | 0 | 1 | KU9T11 | . Based on medical record review, staff interview, and policy review, the facility failed to ensure one (1) of six (6) residents reviewed received the influenza vaccine in 2012. There was a consent to administer the vaccine; however, there was no documented evidence this vaccine was administered. Resident identifier: #87. Facility census: 92. Findings include: a) Resident #87 Review of the medical record, on 04/10/13 at 10:00 a.m., revealed a consent form signed by the resident's medical power of attorney (MPOA) in September 2012 consenting to the administration of the influenza vaccine. Further record review found no evidence Resident #87 received the influenza vaccine during or after September 2012. During an interview with the infection control nurse, Employee #82, on 04/10/13 at 10:15 a.m., she said she recalled giving Resident #87 an influenza vaccination in October 2012, but could produce no evidence other than by memory. She said she wrote the resident's name down on a worksheet, and knew she must have given the vaccination. An interview was conducted with the administrator on 04/10/13 at 10:30 a.m. She clarified that Employee #82 had written, on her own personal worksheet, that she gave the vaccination, but failed to transfer that data to the computer or to the medical record. The administrator produced a copy of the facility's Influenza/Pneumococcal Immunization Guideline. According to page three (3), "The immunization log is to be maintained on the resident's current medical record." Items to be documented included the type of vaccine, the date it was administered, who administered, and the lot number." . | 2015-08-01 |
| 9849 | 9849 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 371 | E | 0 | 1 | KU9T11 | . Based on observation, staff interview, and policy review, the facility failed to store food items in the dietary department in a manner which ensured they were used by a date in which they remained safe to use. The facility's kitchen had opened foods which were not dated to indicate when they were opened. This practice had the potential to affect more than an isolated number of residents who received nourishment from the dietary department. Facility census: 92. Findings include: a) Observations of the kitchen, on 04/01/13, revealed the following: 1) At 12:19 p.m. an undated open container of beef base was observed. During an interview with Employee #97 (cook) and Employee #55 (cook), at 12:20 p.m., they both confirmed the beef base did not have a date. The employees stated the opened food item was supposed to be dated. 2) An observation in the freezer, at 12:21 p.m., revealed a bag of stir-fry and a bag of beef meatballs which did not have dates indicating when they were opened for use. 3) At 12:30 p.m. a bag of opened Hershey chocolate chips was observed. It did not have a date indicating when it was opened for use. 4) On 04/01/13 at 12:35 p.m., a tour of the kitchen was completed with the consultant dietitian (Employee #101). Another tour was completed with the dietary manager on 04/01/13 at 2:00 p.m. They were shown the items of concern, and both confirmed the opened items should have been dated. . | 2015-08-01 |
| 9850 | 9850 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 441 | E | 0 | 1 | KU9T11 | . Based on observation, staff interview, resident interview, and medical record review, the facility failed to maintain an environment free from potential spread of pathogens. Resident #110, with dried blood on his face and hand, went without timely staff intervention. This is true for one (1) of thirty five (35) Stage I residents observed. The facility also failed to store reusable bedpans in a sanitary manner in rooms. This is true for two (2) of thirty eight (38) rooms observed. Resident identifier #110. Room identifiers 106 and 108. Facility census: 92. Findings include: a) Resident #110 Review of the medical record regarding the departure time from dialysis on 04/02/13 found Resident #110 had completed dialysis at 15:30 (3:30 p.m.). A nursing note, written on 04/02/13 stated "Transport reports Dialysis center stated that resident had scratched his face while at their facility." Observation of Resident #110 in the dining room at 4:30 p.m. found the resident had several small scabs on his left cheek and dried blood covering the cheek. His left index and middle fingers were almost entirely covered in dried blood. Resident #110 was interviewed at 4:45 p.m. regarding the blood and he said, "I know, the girls told me." He verified that he was indicating facility staff members were aware of the dried blood. He was observed as he continued to sit in the dining room and was served his evening meal without receiving assistance to remove the blood from his face and hand. According to the most recent Minimum Data Set assessment of 02/09/13, this resident required the extensive assistance of one (1) staff member for personal hygiene. His current care plan also stated he required the extensive assistance of one (1) for personal hygiene. This matter was discussed and confirmed with Employee #82, who is responsible for infection control, on 4/10/13 at 8:45 a.m. | 2015-08-01 |
| 9851 | 9851 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 514 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a complete, accurately documented clinical record for two (2) of thirty-six (36) Stage 2 sample residents. There was no documentation Resident #87 was receiving showers daily. Additionally, there was no documentation Resident #122 was receiving assistance with a bowel and bladder program. Resident identifier: #122 and #87. Facility census: 92. Findings include: a) Resident #122 Medical record review, on 04/08/13 at 2:00 p.m., revealed a physician's orders [REDACTED]. The order also included the resident was to be provided incontinence care every shift and whenever needed. Interview with Employee #54, a nursing supervisor, on 04/08/13 at 5:14 p.m., revealed she placed the resident on the bowel and bladder program on 02/04/13, due to the resident's incontinence. Review of the resident's continence by shift report, on 04/08/13 at 5:30 p.m., revealed the resident was incontinent of urine on a daily basis from 01/15/13 through 04/03/13. The resident's nursing assistant flow sheet, for taking the resident to the toilet, was reviewed on 04/09/13 at 9:00 a.m. There was no documented evidence staff took the resident to the toilet before meals and at bedtime, providing incontinence care every shift and whenever needed. There was also no documentation on the nursing assistant flow sheet, from the start date of 02/04/13 through 03/31/13. The nursing assistant flow sheet had initials of nursing staff only on 04/01/13 through 04/03/13. The resident was discharged on [DATE]. On 04/09/13 at 2:15 p.m., Employee #54, nurse supervisor, and Employee #20, the coordinator of health information (CHI) were interviewed. When asked about nursing assistant flow sheets from 02/04/13 through 03/31/13, regarding documentation of toileting Resident #122, they confirmed the flow sheets could not be found for Resident #122. They stated they had no documented evidence Resident #122 received th… | 2015-08-01 |
| 9852 | 9852 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 272 | D | 0 | 1 | KU9T11 | . Based on a review of the medical record, minimum data set assessment (MDS), and staff interview, the facility did not ensure the accuracy of the MDS assessment for one (1) of thirty six (36) Stage II residents. Resident #21's quarterly assessment incorrectly indicated the resident had broken or ill-fitting dentures. The resident did not have dentures. Resident identifier: #21. Facility census: 92. Findings include: a) Resident #21 On 04/08/13 at 2:45 p.m., a review of Resident #21's quarterly MDS assessment, assessment reference date 03/22/13, Section L0200, indicated the resident had loosely or broken fitting full or partial dentures. On 04/08/13 at 3:00 p.m., Employee #75 (registered nurse/assessment coordinator) indicated she looked in the resident's mouth and verified the resident did not wear dentures. She said the MDS assessment, Section L0200, was coded incorrectly. . | 2015-08-01 |
| 9853 | 9853 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 280 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan for one (1) of thirty-six (36) Stage 2 sample residents who experienced a decline in condition. The care plan in use did not reflect the resident's current status. Resident identifier: Resident #110. Facility census: 92. Findings include: a) Resident #110 Resident #110 had a [DIAGNOSES REDACTED]. Medical record review, on 04/04/13, found nursing notes, dated 03/10/13 and 03/11/13, that described conversations between nursing and the representative of Resident #110 "regarding resident condition and possible hospice consult." At that time, it was determined the resident would have a "hospice referral for palliative care and pain management if need be." A social services note, dated 03/26/13, included ". . . he has had a significant emotional change. Resident has also had physical decline and is now palliative care." On 04/02/13, another social services note stated "Resident needs much encouragement he is depressed and receiving palliative care." Review of current care plan found no indication of any decline in the resident's condition, the provision of palliative care services, or that he was a potential hospice candidate. There was nothing in the care plan addressing a decline in functioning. In fact, one goal regarding physical functioning was "I will improve my current level of physical functioning." This concern was discussed with the MDS Coordinator on 04/09/13 at 12:00 p.m. She was unable to provide information the care plan was revised after the resident's change in condition. . | 2015-08-01 |
| 9854 | 9854 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2015-01-08 | 246 | D | 1 | 0 | YJ9E12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, observation, medical record review, and staff interview, the facility failed to accommodate the needs of one (1) of six (6) sample residents. The resident was not provided a bed proportionate to his size. Resident identifier: #27. Facility census: 84. Findings include: a) Resident #27 On 01/08/15 at 12:00 p.m., review of the resident's medical record found the resident's scheduled pain medications included [MEDICATION NAME] extended release (ER) sixty (60) milligrams twice daily related to chronic pain. At 4:10 p.m. on 01/08/15, an interview was conducted with the resident. He said he took medication for chronic pain daily. He said he would be more comfortable if the bed was longer and fit better. He said the bed nearly "dumped me out on the floor a couple of times" when he turned over, because the bed was so narrow. Observation found that his head was at the top of the mattress, and his heels were very close to the bottom of the mattress. His girth took up most of the width of this standard-sized bed. The resident said he was six (6) feet eight (8) inches tall, or eighty (80) inches. Review of the medical record found this height was accurate. His weight on 01/08/15 was 341 pounds. The director of nursing (DON) and a maintenance employee measured the resident's mattress on 01/08/15 at 4:40 p.m. The mattress measured 83-1/2 inches long. The DON asked the resident if he had not once had a larger bed with an air mattress that he did not like. The resident replied when he returned from a week long stay at the hospital on [DATE], they put him in the present bed. The DON said they would see what they could do about a larger bed. She said the present bed had an extension for the feet. . | 2015-08-01 |
| 9855 | 9855 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2015-01-08 | 280 | D | 1 | 0 | YJ9E12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise the care plans for two (2) of six (6) sampled residents to reflect changes in the residents' conditions. The care plan/interventions for falls and urinary tract infections were not revised after Resident #28 sustained a fall and had a urinary tract infection. The care plan for Resident #27 was not revised to reflect the resident's refusals to be weighed. Resident Identifiers: #28 and #27. Facility Census: 84. Findings Include: a) Resident #28 At 11:10 a.m. on 01/08/15, a review of the care plan for Resident #28 revealed a focus areas for falls. The focus area for falls stated the resident was at risk for falls related to the [DIAGNOSES REDACTED]. The care plan listed actual falls occurred on 05/30/14 and 08/23/14. The goal was for the resident to have no injuries from falls through the next review, with a target date of 03/02/15. Interventions were in place for the focus area of falls. On 01/08/15 at 12:00 p.m., a review of the progress notes revealed a note entered on 12/11/14, stating, " ...resident found face down on floor at 23:40. Sent to ER (emergency room ) for eval (evaluation) and treat (treatment). Physician and RP (responsible party) notified...." At 2:50 p.m. on 01/08/15, a review of the facility's investigation into the fall that occurred on 12/11/14 was conducted. Included in the investigation was a note stating the resident was found face down on the floor beside her bed. She was noted with slight bruising to her face and abdomen. The resident was taken to the hospital for evaluation. A copy of the resident's care plan was requested and obtained at 2:25 p.m. on 01/08/15. During the 01/08/15 review of the care plan for Resident #28, the focus area of urinary tract infections was also identified. The focus area stated the resident was at risk for urinary tract infections due to urinary incontinence and recurrent urinary tract infections. The goal was for … | 2015-08-01 |
| 9856 | 9856 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2015-01-08 | 511 | D | 1 | 0 | YJ9E12 | . Based on medical record and staff interview, the facility failed to promptly notify the resident's physician of the results of a radiology test. Resident #6 had experienced ongoing constipation. The physician ordered an abdominal X-ray and was not notified of the results on the day the results were received at the facility. Resident identifier: #6. Facility census: 84. Findings include: a) Resident #6 On 01/08/14 at 12:30 p.m., review of the medical record for Resident #6 revealed the resident's physician ordered an X-ray of the abdomen on 12/26/14 at 6:59 p.m. due to the resident experiencing ongoing constipation. The progress notes revealed the facility received the results of the x-ray on 12/26/14 at 10:40 p.m. A progress note dated 12/28/14 at 10:15 a.m. stated "Spoke with (physician name) at 10:15 a.m. Returned called about xray results. Very upset that xray was not called into him on 12/26/14. Ordered a stat soap suds enema 500 CC. If no results repeat again in 30 minutes. Also, Stat (immediately) abdominal xray ordered. Awaiting for technicians arrival. Results to be reported to him when results received. First enema given at 10:30 a.m. Resident on bedpan. No results. Resident now up to commode. States she may have better results. Will continue to monitor." On 01/08/14 at 1:30 p.m., the director of nursing said the facility realized they needed to develop a system to ensure the nursing staff received faxes regarding resident test results. Currently the results were faxed to the front office. . | 2015-08-01 |
| 9857 | 9857 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2015-01-08 | 520 | D | 1 | 0 | YJ9E12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to utilize its Quality Assessment and Assurance (QAA) committee effectively regarding resident refusals of medication. The facility failed to notify the physician of the refusals and failed to provide education to the resident as to the potential consequences of the refusals. Resident identifier: #27. Facility census: 84. Findings include: a) Resident #27 Medical record review on 01/08/15 at 12:00 p.m. revealed this [AGE] year old resident was admitted to the facility in September 2014. His [DIAGNOSES REDACTED]. He was prescribed a diuretic, [MEDICATION NAME], 80 (eighty) milligrams twice daily related to [MEDICAL CONDITION]. Review of the nurse progress notes for December 2014 and January 2015 revealed numerous occasions where he had refused the morning dose of [MEDICATION NAME]. There was no evidence nursing staff had notified the physician of these multiple refusals. There was no evidence of nursing education with the resident related to the consequences of continued [MEDICATION NAME] refusals. There was no evidence of communication with the resident to try and find out the reasons for the refusals. Review of the Medication Administration Record [REDACTED]. Review of the MAR for January 2015 revealed he refused his morning dose of [MEDICATION NAME] on 01/03/15, 01/04/15, 01/05/15, 01/06/15, 01/07/15, and 01/08/15. During an interview with the director of nursing (DON) on 01/08/15 at 1:15 p.m., she was asked if there was some evidence the physician had been notified of the resident's refusals of the morning doses of [MEDICATION NAME]. The DON said she would check as she was not very familiar with this resident. On 01/08/15 at 2:25 p.m., in another interview with the DON, she said she contacted the physician that day about the [MEDICATION NAME]. She provided a copy of a nurse progress note dated 01/08/15 with the effective time of 1:41 p.m. and created at 1:46 p.m. The… | 2015-08-01 |
| 9858 | 9858 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2012-08-10 | 252 | C | 0 | 1 | 5XH612 | . Based on observation, resident interview, and staff interview, the facility failed to present a homelike appearance by failing to make beds in a timely manner and/or to provide an appropriately arranged coverlet for the beds that did not leave the mattress, pillows, and/or incontinence pads exposed at the sides. This condition was observed on every hall and in a significant number of rooms. Facility census: 87. Findings include: a) During the general tour at 1:30 p.m. on 08/06/12, two surveyors observed unmade empty beds on all halls. At 2:30 p.m. on 08/06/12, the Director of Nurses was asked if staffing was adequate on that day and she replied that it was. Beds that were made, were done so crudley with coverlets (blankets or bedspreads) that left the mattress, pillows, and/or incontinence pads exposed at the sides. The bedspreads, when used, were folded in half and simply laid atop the bed linens and pillows. This observation was repeated at 10:45 a.m. on 08/07/12, and was very similar to the previous day. At 11:05 a.m. on 08/07/12, Resident #7 was brought into the room by her daughter in a wheelchair. The resident's daughter stated they were returning from a doctor's appointment outside the facility. Resident #7's bed was closed, with a white thin bedspread folded in half and laid over the top of the sheets and pillow. At the sides an incontinence pad and a lift sheet could be seen, and the cover was not molded around the pillow. When asked if this was how the bed was usually made-up, they stated yes, although both were quick to add that they had no complaints about the care and understood it could not be "like home" and the resident would not have to stay there long. During an interview with the Director of Nurses, at 11:20 a.m on 08/07/12, these findings were shared with her and some of the rooms were viewed, including room 137. She stated that she would rectify the situation. . | 2015-08-01 |
| 9859 | 9859 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2010-12-02 | 280 | D | 0 | 1 | NE1Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to review the care plan for one (1) of thirty-three (33) Stage II sampled residents as the treatment modalities being used were changed by direct care staff. Posey cone hand splints (suggested by the occupational therapist and subsequently ordered by the physician), to maintain the highest level of range of motion and to prevent further decline of a resident with contractures, were not being used and had been replaced with rolled wash cloths, although the care plan indicated that the cone splints were still to be used. Resident identifier: #170. BJH facility census: 111. Findings include: a) Resident #170 A review of Resident #170's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. No contractures were noted on his admission history and physical, but on 03/04/10, the attending physician ordered the application of a Posey palm cone splint to the left hand for contractures of fingers to be used during waking hours, after identification of the contractures by an occupational therapy assessment. On 07/26/10, the attending physician ordered, "Occupational therapy: For right hand cone splint due to right 4th and 5th finger contractures. DX (diagnosis): Finger contractures." On 08/27/10, the orders were clarified to state, "Bilateral Posey cones to right and left hands on during awake hrs (sic) off at HS (bedtime)." The care plan, completed on 09/09/10, did not include these ordered splints in their interventions, and there was no evidence that their use had been discussed at the care plan conference on that date. But the use of the cone hand splints had been handwritten on the care plan on an undetermined date after that day as an intervention to prevent "altered skin integrity" and under the stated problem of "self-care deficit". A review of the care plan conference schedule revealed the next conference … | 2015-08-01 |
| 9860 | 9860 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2010-12-02 | 318 | D | 0 | 1 | NE1Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to ensure hand splints recommended by the occupational therapist and subsequently ordered by the physician (to maintain the highest level of range of motion and to prevent further decline of a resident with contractures) were being used consistently as instructed for one (1) of thirty-three (33) Stage II sampled residents. Resident identifier: #170. BJH facility census: 111. Findings include: a) Resident #170 A review of Resident #170's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. No contractures were noted on his admission history and physical, but on 03/04/10, the attending physician ordered the application of a Posey palm cone splint to the left hand for contractures of fingers to be used during waking hours, after identification of the contractures by an occupational therapy (OT) assessment. In an OT completed on 07/28/10, the therapist described the worsening of the resident's contractures as follows: "R (right) hand 4th and 5th digits held clenched throughout the day (sign for 'with') indentation in palm from 5th digit fingernail, causing concern for skin integrity in the future. Resident has full PROM (passive range of motion) of all digits R hand. Resident has tolerated a palm cone during waking hours in the L (left) hand since March 2010 for similar problems, therefore I recommend use of a R hand palmcone to provide passive stretch to the 4th and 5th digits as well as to promote palmar skin integrity in the future." On 07/26/10, the attending physician ordered, "Occupational therapy: For right hand cone splint due to right 4th and 5th finger contractures. DX (diagnosis): Finger contractures." On 07/30/10, the OT daily progress notes stated the cone was being tolerated and that therapy services were being discontinued. This was verified in an interview with the occupational therapist (E… | 2015-08-01 |
| 9861 | 9861 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2010-12-02 | 356 | C | 0 | 1 | NE1Z11 | . Based on observation and staff interview, the facility failed to ensure the posted nurse staffing information included all of the requirements in Federal statute 42 CFR 483.30 (e), by failing to include the number of actual hours worked by nursing staff. This had the potential to affect all residents and visitors. BHJ facility census: 111. Findings include: a) During a tour of the environment at 1:00 p.m. on 12/01/10, the "Nursing Staffing / Resident Census" forms were observed posted on each floor. The posting included the facility's name, the current date, the resident census, and the total number of registered nurses, licensed practical nurses, and certified nurse aides. However, the number of actual hours worked by each of these categories of nursing staff were not listed on the form. During an interview with the director of nurses (DON) and the 100 hall nurse manager at 3:50 p.m. on 12/01/10, the DON expressed surprise that the hours were required and stated they had never included them in their posting. At her request, she was provided with the Federal statute 42 CFR 483.30 (e) at 9:00 a.m. on 12/02/10. . | 2015-08-01 |
| 9862 | 9862 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2010-12-02 | 431 | E | 0 | 1 | NE1Z11 | . Based on observation and staff interview, the facility failed to maintain the secure storage of medications and syringes on the medication cart at a time when it was unattended and located in a hallway traveled by residents and/or visitors. This had the potential to affect anyone who could reach the top of the cart on the 100 hall. BHJ facility census: 111. Findings include: a) During medication pass by a licensed practical nurse (LPN - Employee #8) on the 100 hall on the afternoon of 11/29/10, observation found multiple vials of insulin and syringes located on top of the medication cart. The nurse left the cart unattended on four (4) separate occasions while she entered rooms 124, 125, 127, and 134, to administer medications to those residents. The cart was left unattended and out of line of sight of the nurse in the hallway intermittently from 1:30 p.m. to 1:59 p.m., and the items on top of the cart were accessible to anyone passing in the hallway. During an interview with Employee #8 at 2:15 p.m. (at the conclusion of the observation), she acknowledged the medications and syringes were left out on the top of the cart, and she placed them inside of a drawer. | 2015-08-01 |
| 9863 | 9863 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-08-23 | 225 | D | 1 | 0 | XBKB11 | . Based upon record review, review of the facility's complaint files, review of incident reports, and staff interview, the facility failed to ensure that an alleged violation involving mistreatment, neglect, or abuse was reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). This was found for one (1) of six (6) documented complaints received by the facility during 2012. Resident identifier: #23. Facility census: 65. Findings include: a) Resident #23 The facility's complaint files were reviewed on 08/20/12 at 2:50 p.m. There was a documented complaint dated 04/12/12. The daughter of Resident #23 came to the nurses' station at 7:45 p.m. She had found her mother sitting in the dark in her room in her wheelchair soaked in urine, and her prosthetic sleeve was dirty and had a foul odor. When she asked for disinfectant to clean it, she was given a can of stainless steel cleaner. Facility documentation was made on an incident report form. Under the sections "Contributing Factors" and "Prevention" was recorded "Resident should have been put to bed once the CNA (nursing assistant) put resident in the room. (Local church group was wanting staff to take residents to church on NCFII (one of two separated units in the facility). It was also shift change. Having staffing problems." The witness statement that was completed by the nursing assistant providing care included the statement "The whole time, (resident's daughter) is telling us 'this is neglect and abuse. . . .'" The incident report completed by the nurse under the section "Type of Incident" stated "Abuse/Neglect". There was no indication the allegation had been reported to any outside agencies. There was no record of reporting in the facility's abuse/neglect reporting logs when that information was reviewed on 8/20/12 at 1:50 p.m. b) The social worker, Employee #63, who assumed her duties at the facility on 07/09/12, was inter… | 2015-08-01 |
| 9864 | 9864 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-08-23 | 244 | E | 1 | 0 | XBKB11 | . Based upon review of facility documents, resident interview, and staff interview, the facility failed to act upon the grievances and recommendations of residents regarding staffing and lack of timely response to call lights. This was also cited during the annual survey of 01/31/12, and had the potential to affect more than an isolated number of residents. Facility census: 65. Findings include: a) Review of the resident council meeting minutes, on 8/20/12 at 2:00 p.m., found that during the meeting of 06/28/12, four (4) residents expressed concerns about staff response to call lights. The minutes (typed as written) stated: "Call Lights and Call Response Time 20 minute wait and Bells being turned off." This concern was then found included on a complaint form which was also dated 06/28/12. Under the "Report of complaint investigation" section, the former director of social services had documented (typed as written): "General consensus that the call bells were not always answered promptly However no specific dates or times given Call light/bell study - all shifts in various rooms to determine length of response and develop system for faster results/response times". The section "Was complaint valid?" was checked "yes". The results of the Call light/bell study were requested from the administrator, Employee #64, on 8/22/12 at 3:00 p.m. On 08/23/12 at 8:08 a.m., the administrator stated that no audit was completed and no response was ever made to the residents. b) Resident #26, who was one of the residents that expressed concerns during the Resident Council meeting of 06/28/12, was interviewed on 08/22/12 at 3:20 p.m. She confirmed that call light response continued to be a problem due to insufficient staff, stating "No, there is absolutely not enough. If they are busy with someone else, you can wait a half hour or even an hour for toileting, getting in and out of bed, and so forth. They are all very nice to us, and do their best, but they can't keep up with it. Anybody you ask will tell you that except for the big bo… | 2015-08-01 |
| 9865 | 9865 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-08-23 | 323 | G | 1 | 0 | XBKB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based upon record review, staff interview, and observation, the facility failed to provide adequate supervision to prevent accidents and ensure the resident environment remained as free of accident hazards as possible. This resulted in falls and injury to one (1) resident. Two (2) of nine (9) residents on the sample were affected. Facility census: 65. (This was also cited during the annual survey of 01/31/12) Findings include: a) Resident #28 This [AGE] year old lady was readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was found to have had a fall with a fracture on 03/23/12, a second fall on 06/08/12, and another fall with a fracture on 07/24/12. Her record was reviewed on 08/20/12 at 10:35 a.m. She had been assessed as being at risk for falls since her admission. Her comprehensive minimum data set (MDS) assessment, of 06/07/12, indicated she was not steady, only able to stabilize with staff assistance for moving from a seated to a standing position, walking, turning around, moving on and off of the toilet, and surface-to-surface transfers. She was assessed as being at risk for falls due to poor balance, psychotropic drug use, and poor safety awareness related to her dementia. She also had a built-up shoe for her right foot due to the right leg being shorter than her left. A review of her care plan found there was an intervention in place as early as 03/17/12 that stated "Do not leave alone in bathroom, activity, or hairdressing rooms." The KARDEX, or specific instructions for the nursing assistants concerning individualized care to be provided for Resident #28, contained the statement under the "comments" section: "Resident is not to be left alone in BR (bathroom)." The incident report of 03/23/12, for her fall with fracture, indicated she fell when left unattended by staff. Under the "Prevention" section was documented: "Two staff members should've remained with the resident until resident was seated in the wheelchair.… | 2015-08-01 |
| 9866 | 9866 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-08-23 | 353 | E | 1 | 0 | XBKB11 | . Based upon record review, resident interview, confidential staff interviews, and staff interview, the facility failed to ensure adequate staffing levels across all shifts to meet the needs of dependent residents such as assisting the residents to the bathroom and answering call lights in a timely manner. This had the potential to affect all residents who were dependent or required staff assistance. Facility census: 65. Findings include: a) Review of the facility complaint files on 8/20/12 at 2:50 p.m. found a documented complaint dated 04/12/12. The daughter of Resident #23 came to the nursing station at 7:45 p.m. She had found her mother sitting in the dark in her room in her wheelchair soaked in urine. Facility documentation was made on an incident report. Under the sections "Contributing Factors" and "Prevention" was recorded "Resident should have been put to bed once the CNA put resident in the room. (Local church group was wanting staff to take residents to church on NCFII (one of two separated units in the facility). It was also shift change. Having staffing problems." b) Review of facility resident council meeting minutes, on 8/20/12 at 2:00 p.m., found that during the meeting of 06/28/12, four (4) residents had expressed concerns about staff response to call lights. The minutes (typed as written) stated: "Call Lights and Call Response Time 20 minute wait and Bells being turned off." This concern was then found included on a complaint form which was also dated 6/28/12. Under the "Report of complaint investigation" section, the former director of social services had documented (typed as written): General consensus that the call bells were not always answered promptly However no specific dates or times given Call light/bell study - all shifts in various rooms to determine length of response and develop system for faster results/response times. The section "Was complaint valid?" was checked "yes". The results of the Call light/bell study were requested from the administrator, Employee #64 on 8/22/12 at 3:00… | 2015-08-01 |
| 9867 | 9867 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-08-23 | 386 | E | 1 | 0 | XBKB11 | . Based upon record review and staff interview, the facility failed to ensure a physician reviewed the residents' care at the time of each visit by signing and dating all orders in a timely manner as required. This was found for four (4) of six (6) residents whose records were reviewed This had the potential to affect more than an isolated number of residents. Facility census: 65. (This was also cited during the annual survey of 01/31/12.) Findings include: a) Resident #2 The medical record of Resident #2 was reviewed on 08/22/12 at 8:00 a.m. She was seen by a physician on 07/16/12, but orders remained unsigned going back to 07/01/12. b) Resident #65 The medical record was reviewed on 08/22/12 at 8:10 a.m. She was seen by a physician on 07/16/12, but orders remain unsigned going back to 07/1/12. c) Resident #54 The medical record was reviewed on 08/22/12 at 8:18 a.m. There were unsigned orders going back as far as 06/01/12. d) Resident #46 The medical record was reviewed on 08/22/12 at 8:35 a.m. There were unsigned orders as far back as 03/01/12. e) The medical records coordinator, Employee #99, was interviewed on 08/22/12 at 9:42 a.m. She stated the plan of correction for the annual survey of 01/31/12 was that the Administrator conducted a monthly audit by the first Tuesday of every month for physicians' compliance and then gave the results to her for letters to be sent to physicians who were non-compliant. The physicians were to have five (5) days to complete the required documentation, or would face possible suspension by the hospital's Long Term Care Committee. She stated she had not received an audit since May 2012, and the last letter she sent to physicians was on 06/13/12. Prior to that, the last audit she received was in January 2012, which resulted in a letter being sent to physicians on 02/23/12. She acknowledged there were continued problems with orders not being signed in a timely manner. f) The administrator, Employee #64, was interviewed on 08/23/12 at 9:00 a.m. She stated she had hand delivered let… | 2015-08-01 |
| 9868 | 9868 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-08-23 | 490 | G | 1 | 0 | XBKB11 | . Based upon record review, resident interview, and staff interview, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident from a failure to correct deficient practices identified on the annual survey of 01/31/12. The facility had failed to complete all elements of the approved plan of correction, or implemented other corrective actions, in the areas of preventing injury from accidents, which was found for two (2) of nine (9) residents reviewed; responding and acting upon group grievances, which was found for one (1) complaint and had the potential to affect more than an isolated number of residents; and ensuring that physician's orders were signed in a timely manner, which was found for four (4) of six (6) records reviewed. All residents had the potential to be affected. Facility census: 65. Findings include: a) The facility was cited for failure to provide adequate supervision to prevent accidents for Resident #28. The resident was left alone while on the toilet which resulted in a fall with a fracture. Additionally, the facility had not ensured the resident environment remained as free of accident hazards as possible, which was found for Resident #48. A bedside commode that had been identified as an accident hazard was observed to remain in the resident's room throughout the survey. The facility was cited for the same deficient practices during the annual survey ending 01/31/12, and had submitted an approved plan of correction designed to address staff responsiveness to resident's needs and environmental hazards by 03/31/12. (See F323) b) The facility failed to respond to, and act upon, group grievances. Members of the resident council had expressed concern with call lights not being answered in a timely manner during their meeting of 06/28/12. The facility was to conduct an audit in an effort to investigate the concern, but this… | 2015-08-01 |
| 9869 | 9869 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-08-23 | 520 | G | 1 | 0 | XBKB11 | . Based upon observation, record review, staff interview, and resident interview, the facility failed to maintain a quality assessment and assurance committee that developed and implemented appropriate plans of action to correct identified quality deficiencies in the areas of preventing injury from accidents, which was found for two (2) of nine (9) residents reviewed; responding and acting upon group grievances, which was found for one (1) complaint and had the potential to affect more than an isolated number of residents; and ensuring that physician's orders were signed in a timely manner, which was found for four (4) of six (6) records reviewed. These issues had the potential to affect all residents. Facility census: 65. Findings include: a) The facility was cited for failure to provide adequate supervision to prevent accidents for Resident #28. The resident was left alone while on the toilet which resulted in a fall with a fracture. Additionally, the facility had not ensured the resident environment remained as free of accident hazards as possible, which was found for Resident #48. A bedside commode that had been identified as an accident hazard was observed to remain in the resident's room throughout the survey. The facility was cited for the same deficient practices during the annual survey ending 01/31/12, and had submitted an approved plan of correction designed to address staff responsiveness to resident's needs and environmental hazards by 03/31/12. (See F323) b) The facility failed to respond to, and act upon, group grievances. Members of the resident council had expressed concern with call lights not being answered in a timely manner during their meeting of 06/28/12. The facility was to conduct an audit in an effort to investigate the concern, but this was never done. There was never any response given to the council regarding the issue. The facility was cited for the same deficient practice during the annual survey ending 01/31/12. A plan of correction had been submitted that was designed to address t… | 2015-08-01 |
| 9870 | 9870 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-11-07 | 465 | B | 1 | 0 | XBKB12 | . Based on observation and staff interview, the facility failed to provide a safe and sanitary environment for the residents, staff, and the public in the long term care area located on the second floor of the main hospital building, by failing to keep the perimeters of the floors in the diet kitchen, the hallways, and the elevators clean and free of debris. This had the potential to affect all who came to this area. Facility census: 66. Findings include: a) During a follow-up tour of NCF II (Nursing Care Facility II is the unit located on the second floor of the main hospital building), at 12:45 p.m. on 11/05/07, the floor of the diet kitchen was observed to be dirty overall and grime around baseboards and pipes (near the ice machine). There were papers and debris, including a wash basin on the floor under the cabinets. The floors along the edges, near the baseboards, both in rooms and hallways were unclean. The thresholds of each room were also in need of cleaning. In the soiled utility room, the metal cabinet under the sink was rusted (completely through in spots). While there were no sterile supplies or supplies for direct resident care, there were new red (infectious waste) bags and other supplies stored there. The elevator tracks were dirty and filled with debris. Employee #67 (RN) was present in the diet kitchen at 1:00 p.m. on 11/06/12, and agreed the floor needed cleaned. The DON was informed shortly after and visited the area on her own. During an interview with the head of housekeeping (Employee #64), at 2:08 p.m. the same day, Employee #64 first stated they had a new employee working on this floor, but had no answer when it was pointed out to her the areas described had grime that was not of recent origin. She stated she would schedule these floors to be stripped and cleaned. . | 2015-08-01 |
| 9871 | 9871 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-11-07 | 253 | B | 1 | 0 | XBKB12 | . Based on observation and staff interview, the facility failed to provide adequate housekeeping to ensure a clean and orderly environment by failing to keep the outer perimeters of the floors, both in the residents' rooms and in the hallways of the nursing unit located on the second floor of the main hospital, clean. This had the potential to affect all residents (24) residing in this location. Facility census: 66. Findings include: a) During the initial tour of NCF II (Nursing Care Facility II is the unit located on the second floor of the main hospital building), at 12:15 p.m. on 11/05/07, the floors along the edges, near the baseboards, both in rooms and hallways were noted to be in need of cleaning. The thresholds of each room were also unclean in appearance. A revisit to NCF II, at 12:45 p.m. on 11/06/12, revealed the floors were still grimy at the edges in both rooms and hallways. These observations were reported to the DON at 1:00 p.m. on 11/06/12, and discussed with the head of housekeeping (Employee #64) at 2:08 p.m. the same day. Employee #64 first stated they had a new employee working on this floor, but had no answer when it was pointed out to her that the areas described had grime that were not of recent origin. She stated she would schedule these floors to be stripped and cleaned. . | 2015-08-01 |
| 9872 | 9872 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-12-18 | 282 | D | 0 | 1 | GZSS12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the [MEDICAL TREATMENT] communication records, and staff interview, the facility failed to follow the care plan for post [MEDICAL TREATMENT] care for one (1) of one (1) sample residents. The facility failed to assess the resident, as indicated in the care plan, upon return to the facility from the [MEDICAL TREATMENT] unit. Resident identifier: #65. Facility census: 58. Findings include: a) Resident #65 A review of the care plan for Resident #65, on 12/16/14 at 10:43 a.m., revealed the following interventions, dated 11/20/14: "Upon arriving to facility from [MEDICAL TREATMENT] check that dressing to access site dry and intact, check for presence of thrill and bruit, check for presence of a pulse in the affected arm, present of [MEDICAL CONDITION] of the hand, and capillary refill of fingers, check vital signs and weight." On 12/16/14 at 10:57 a.m., a review of the nurses' notes, typed as written, revealed the following: - "11/28/14 at 16:30 (4:30 p.m.) Returned to the facility safely at 16:30 Pm.No N/V (nausea and vomiting). BP (blood pressure) 142/70 mmHg (millimeters of mercury), Temp (temperature) 98.4, P (pulse) 70 and R (respirations) 20. And Post-WT (weight) [MEDICAL TREATMENT] was 110.6 lbs (pounds), and 1.9 lbs withdrawn.Dsg (dressing) to [MEDICAL TREATMENT] site to L)UA (left upper arm) patent, dry and no s/s (signs/symptoms) of infection.Bruit and thrill present.No C/O (complaints) pain or discomfort.resting in bed quietly. - 12/01/14 at 16:00 (4:00 p.m.) resident returned safely at this time. VS:BP130/66 mmhg, Temp [MEDICATION NAME] and [MEDICATION NAME] taken at 2pm at [MEDICAL TREATMENT].No N/V. The [MEDICAL TREATMENT] port site to LUA covered w/ (with) pressure dsg (dressing), and patent, dry. No redness or bleeding.Bruit and thrill positive.Resting in bed quietly. Pre WT was 108.7 lbs and post-Wt was 102.8 lbs, 5.7 lbs withdrawn by [MEDICAL TREATMENT]. - 12/03/14 16:30 (4:30 p.m.) Retu… | 2015-08-01 |
| 9873 | 9873 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-12-01 | 244 | B | 0 | 1 | ENOI11 | . Based upon review of facility documentation, resident interview, and staff interview, the facility did not notify and/or discuss a proposed change in dining services with residents prior to implementing the change, and did not adequately address grievances that were expressed following the implementation of the change. This had the potential to affect more than an isolated number of residents. Facility census: 85. Findings include: a) Prior to entry for the survey, the regional ombudsman had advised the survey team that there had been concerns expressed over the facility stopping the practice of providing soda for residents. Resident #14, the vice president of resident council, and the resident who led the last three (3) council meetings of 9/30/11, 10/21/11, and 11/18/11, was interviewed on 11/28/11 at 10:45 a.m. She was asked about any resident council concerns regarding the facility providing soda to residents in recent months. She replied that the facility had stopped providing soda, and now they only got soda during some activities, or had to buy it from the machine. She said several residents were upset by this. She was asked for permission to review the minutes of recent resident council meetings, which she granted. b) Resident council meeting minutes for 8/26/11, 9/30/11, 10/2/11, and 11/18/11 were reviewed on 11/29/11 at 9:00 a.m. The minutes for the 11/30/11 meeting had concerns noted for the dietary department, including (typed as written): "Suppose to have lemonade to replace soda" and "Don't like having the soda taken away." The facility grievance file was reviewed on 11/29/11 at 9:30 a.m. A complaint was found from 10/4/11, which stated: (typed as written): "Resident requested soda, staff informed resident that facility no longer provides soda. POA (power of attorney) stated back to employee, 'Don't you think it is awful to pay $7,200.00 per month and can't get a soda.'" The resolution as documented was that "activity dept. is to provide soda during room visits." No other documentation was found t… | 2015-08-01 |
| 9874 | 9874 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-12-01 | 280 | D | 0 | 1 | ENOI11 | . Based on resident interview, record review, and staff interview, the facility failed, for one (1) of thirty-seven (37) sample residents, to follow a resident's care plan to encourage him "to drink fluids of choice',and failed to assure the resident participated in the planning his care and treatment after the facility discontinued serving sodas, the resident's fluid of choice. Facility census: 85. Resident identifier: #39 Findings include: a) Resident #39 Interview with Resident #39 on 11/29/11 at 10:16 a.m. revealed he would prefer to have soda pop with some of his lunch and supper meals, but the facility will no longer serve sodas with meals. Review of Resident #39's medical record revealed he was prescribed a regular diet with no added salt (NAS). During an interview with the dietary manager, on 11/29/11 around noon, she agreed the facility no longer served sodas with meals because it was deemed to be not a healthful item. When asked how long this practice of not allowing sodas with meals has been in effect, she stated the change probably took place sometime in September 2011. When asked what dietary differences there were between a regular diet and a no added salt (NAS) diet, she stated the residents receive all the same foods, they just do not receive a salt packet on the tray if on a NAS diet. Review of the care plan for Resident #39 revealed he had care plan goals related to his obesity; and care plan goals related to potential fluid deficit related to diuretic use, and needing encouragement with fluid intake in order to meet daily requirements. A goal for the potential fluid deficit was to "encourage me to drink fluids of choice". The resident's fluid of choice was soda. When the facility decided to discontinue serving residents sodas, the resident was not consulted regarding the change. Additionally, the resident was not afforded the opportunity to participate in planning what fluids he would like instead. During a second interview with Resident #39 on 11/30/11 at 5:00 p.m., he stated he received milk … | 2015-08-01 |
| 9875 | 9875 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-12-01 | 329 | D | 0 | 1 | ENOI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, and staff interview, the facility failed to provide justification for the use of as needed (PRN) [MEDICATION NAME], a sedating drug, for one (1) of thirty-seven (37) sample residents. Resident #78 had a physician's orders [REDACTED]." Review of the Medication Administration Record [REDACTED]. Additionally, there was no evidence that non-pharmacological interventions had been attempted to control behaviors prior to giving [MEDICATION NAME]. This made the use of [MEDICATION NAME] an unnecessary drug. Resident identifier: # 78. Facility census: 85. Findings include: a) Resident #78 During the medical record review, it was discovered the physician had written an order, on 09/12/11 at 3:30 p.m., for [MEDICATION NAME] 0.5mg. one(1) tablet by mouth every evening for "severe agitation only." Review of physician progress notes [REDACTED]. During a review of nursing notes, dated 09/12/11 at 7:30 p.m, documentation revealed "Resident very confused calling at staff and even tried to hit staff, [MEDICATION NAME] 0.5mg given po (by mouth) @ (symbol for at) this time". There was no documentation indicating non-pharmacological interventions had been attempted prior to giving the [MEDICATION NAME]. Further review of the MAR indicated [REDACTED]. During a review of nursing notes it was found there had been no documentation about the resident's behaviors indicating the need for [MEDICATION NAME]. Further review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. There was no documentation which indicated the resident's behaviors which necessitated theuse of [MEDICATION NAME]. During an interview with the director of nursing (Employee # 54), on 12/01/11 at 9:20 a.m., it was agreed the nursing documentation failed to describe behaviors, and what behaviors should be considered severe. It was also agreed there was no evidence non-pharmacological interventions had been attempted before the [MEDICATION NA… | 2015-08-01 |
| 9876 | 9876 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-07-26 | 225 | D | 1 | 0 | 2QL911 | . Based on medical record review, abuse/neglect reportable allegations review, and staff interview, the facility failed to ensure all reportable allegations of neglect were thoroughly investigated. A review of the reportable allegations of abuse and neglect for June 2012 and July 2012 revealed one (1) allegation for which the facility had not conducted a thorough investigation. Resident identifier: #116. Facility census: 114. Findings include: a) Resident #116 On 07/24/12, at approximately 1:00 p.m., a review of the reportable allegations of abuse and neglect for June 2012 and July 2012 revealed the facility had not thoroughly investigated one (1) of the allegations. The allegation, dated 07/09/12, involved Resident #116. The allegation was recorded as "On 07/09/12, the resident complained she did not get pain medications as ordered." The outcome of the facility's investigation indicated the resident received prn (as needed) pain medications and did not request the medication throughout the night of 07/08/12. The facility had obtained statements from nursing staff. They also had reviewed the resident's Medication Administration Record [REDACTED]. A review of the statements gathered by the social worker (Employee #18) reflected a registered nurse (Employee #65) had not signed her statement. On 07/24/12, at approximately 4:00 p.m., Employee #65 reviewed the statement that social services had taken from her. She indicated the statement did not accurately reflect her account of the events involving Resident #116 on 07/08/12. The registered nurse confirmed she had not reviewed this statement, nor had the she signed or dated the statement. Other statements contained in the investigation were also lacking the signatures of witnesses. On 07/24/12 at 5:00 p.m., the director of nursing (Employee #2) said the facility had recently changed the manner in which abuse/neglect investigations were conducted. She said social services had taken over this role where as in the past the administrator and director of nursing were more … | 2015-08-01 |
| 9877 | 9877 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-07-26 | 514 | D | 1 | 0 | 2QL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, abuse/neglect reportable allegation review, and staff interview, the facility failed to ensure one (1) of nine (9) residents had a medical record that was maintained in accordance with accepted professional standards and practices which includes the records be complete and accurately documented. Resident identifier: #116. Facility census: 114. Findings include: a) Resident #116 On 07/24/12 at 12:00 p.m., the reportable allegations of abuse/neglect review revealed an allegation involving Resident #116. The resident had alleged she did not receive her pain medication ([MEDICATION NAME] 10/325 mg) on the night of 07/08/12. The medical record review revealed the physician had ordered the pain medication every four (4) hours as needed. The facility had contacted the physician and pharmacy on 07/08/12 and a new prescription of the medication arrived on the morning of 07/09/12. The narcotics sign out sheet revealed the facility did have thirty (30) tablets of [MEDICATION NAME] 10/325 mg at 8:00 a.m. on 07/09/12. The resident received a dose at that time On 07/24/12 at 3:00 p.m., the social worker (Employee #18) stated she investigate this allegation of neglect and had found the allegation unsubstantiated. Her investigation included a review of the resident's Medication Administration Record [REDACTED] On 07/24/12 at 4:00 p.m., Employee #65 (registered nurse) stated she came on duty at 11:00 p.m. and at that time Resident #116 had asked about her pain medication. The resident had received a dose of [MEDICATION NAME] 10/325 mg at 8:00 p.m. Employee #65 said she explained to the resident the situation involving the need to get a new prescription of [MEDICATION NAME]. She told the resident the pharmacy would deliver the new prescription on the morning of 07/09/12. Employee #65 said she informed the resident she could contact the physician and ask for an alternate pain medication. The resident declined. According to the … | 2015-08-01 |
| 9878 | 9878 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2013-05-17 | 155 | D | 0 | 1 | RKHC12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, resident interview, and policy review, the facility failed to assist two (2) of three (3) residents, reviewed for decision making, to formulate an advance directive, stating their desire to receive or not to receive cardiopulmonary resuscitation (CPR). Resident #193's wishes were to receive CPR if she was found to have no pulse, respirations and/or blood pressure. This was not assessed by the facility. She had a physician's orders [REDACTED]. Resident #217 had a Physician order [REDACTED].#217. The form was signed by her medical power of attorney (MPOA); however the resident still maintained capacity to make medical decisions. Resident identifiers: #193 and #217. Facility Census: 113 Findings Include: a) Resident #193 A medical record review was completed at 9:20 a.m. on [DATE]. This review revealed the resident had an order for [REDACTED]. The resident was readmitted to the facility from an acute care hospital on [DATE]. A care plan conference summary sheet was reviewed. It noted the resident wanted to be a "Full Code." This indicated the resident wanted to have CPR initiated should it be needed. This summary was signed by Employee #36, a Registered Nurse (RN), minimum data set (MDS) Coordinator, Employee #51, Social Worker, a Licensed Physical Therapy Assistant, a Certified Occupational Therapy Assistant, and Resident #193. The resident's care plan was also reviewed. The care plan contained the following problem, "The resident desires to be a DNR." The goal contained on the care plan was, "DNR will be honored upon absence of pulse, respirations, and/or blood pressure." The care plan contained the following interventions. "1. Verify the absence of apical pulse, respirations, and/or blood pressure. 2. Notify Physician. 3. Notify Family." Additional review of the medical record revealed a hospital discharge summary, dated [DATE], which contained the following statements: "It was questioned whe… | 2015-08-01 |
| 9879 | 9879 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2013-05-17 | 250 | D | 0 | 1 | RKHC12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, staff interview, medical record review, and policy review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well being for two (2) of three (3) sample residents. The facility failed to ensure the desire for resuscitation was correctly noted for one (1) resident, and the Medical Power of Attorney (MPOA) was allowed to make the resuscitation decision for one (1) resident who retained capacity to make her own medical decisions. Resident #193's wishes were to receive cardiopulmonary ressucitation (CPR) if she was found to have no pulse, respirations and/or blood pressure. This was not assessed by the facility, and she had a physician's orders [REDACTED]. Resident #217 had a Physician order [REDACTED]. This form was not signed by the resident. The form was signed by her medical power of attorney (MPOA); however the resident still maintained capacity to make medical decisions. Resident Identifiers: #193 and #217. Facility Census: 113. Findings include: a) Resident #193 A medical record review was completed at 9:20 a.m. on [DATE]. This review revealed the resident had an order for [REDACTED]. This order was contained on the resident's active monthly orders for the month of [DATE]. The orders contained an order date of [DATE] and a start date of [DATE]. The resident was readmitted to the facility from an acute care hospital on [DATE]. The medical record did not contain evidence to suggest the facility reviewed with the resident her wishes in regards to advance directives upon her readmission to the facility. At 9:45 a.m. on [DATE], a resident interview was conducted with Resident #193. The resident was alert and orientated to time, place and person. She was able to answer questions appropriately. She was asked if she had told the facility what her wishes were in regards to CPR. She stated, "I have never really thought about w… | 2015-08-01 |
| 9880 | 9880 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-05-09 | 156 | C | 1 | 0 | SZNR11 | . Based on record review and staff interview, the facility failed to ensure three (3) of three (3) resident's received the appropriate discharge notice, as required by the Centers for Medicare and Medicaid Services (CMS), after they were discharged from a Medicare skilled service. Resident #22, Resident #72, and Resident #39 were all discharged from Medicare Part A skilled services in April 2012. The facility did not issue one (1) of two (2) notices at the time Medicare Part A services ended. Facility census: 77. Findings include: a) Resident #22 This resident was discharged from Medicare Part A, on 04/21/12, due to no further skilled services being available for her. b) Resident #72 This resident was discharged from Medicare Part A, on 04/15/12, due to no further skilled services being available for her. c) Resident #39 This resident was discharged from Medicare Part A, on 04/26/12, due to a completion of antibiotic therapy. d) An interview with Employee #10 (business office manager), on 05/09/12 at 1:00 p.m., revealed these three (3) residents had received the Notice of Non Coverage, CMS form ( ). The generic notice (form ) simply informs the resident of their right to an expedited review of the service termination for coverage reasons. The facility must issue the skilled nursing advanced beneficiary notice to address the resident's potential liability for payment if they remain in the facility. The residents had not received the Skilled Nursing Advanced Beneficiary Notice (SNFABN). According to the business office manager, all three (3) residents remained in the facility under another payer source. The facility needed to give the three (3) residents both notices because all Medicare covered services were ending and the center intended to deliver non-covered care. The SNFABN is given because benefit days remain to inform the resident of potential financial liability. . | 2015-08-01 |
| 9881 | 9881 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-05-09 | 203 | D | 1 | 0 | SZNR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a closed medical record review and staff interview, the facility failed to ensure two (2) of five (5) residents were provided with a written discharge notice thirty (30) days prior to their discharge date s. This notice must include the reason for discharge, the effective date, the location to which the resident was being discharged , the right to appeal, how to notify the ombudsman, and how to notify appropriate protection and advocacy agencies. Resident identifiers: #57 and #85. Facility census: 77. Findings include: a) Resident #57 The medical record review for Resident #57, conducted on 05/08/12, at approximately 1:00 p.m., revealed this eighty seven (87) year resident was admitted to the facility on [DATE]. The resident left the faciity on [DATE]. According to the medical record, she now resides in a personal care home. Medical record review revealed several social service and nursing notes, dating back to November 2011, reflecting the resident's desire to return home. The facility completed a pre admission screening (PAS) on the resident. A progress note, dated 05/01/12, stated, "Resident is in process of discharge planning. She no longer qualifies for nursing home care. At this point plans will be for her to go to (name of personal care home). The ombudsman will be here on Wednesday 05/02/12 to meet with res. and her family. The son who is health care surrogate will not transport to new facility. He wants her transferred by ambulance. " Another progress note, dated 05/04/12, stated, "Resident d/c (discharged ) to a personal care home due to no longer being eligible for nursing home level of care. Her son has made all the financial needs for the transfer. " On 05/09/12, at approximately 11:00 a.m., the former business office manager (Employee #65) and the medical records clerk (Employee #14) reviewed the resident's closed record. The record did not contain information indicating the health care surrogate was provided a thirty… | 2015-08-01 |
| 9882 | 9882 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2011-08-11 | 328 | E | 0 | 1 | MU6H12 | . Based on observation, staff interview, and policy review, the facility failed to follow its own policy with respect to the use of an oxygen delivery system for a maximum of seven (7) days and/or to dating the oxygen humidifier bottle and oxygen tubing when changed. This was evident for three (3) of fifteen (15) sampled residents, and for three (3) randomly observed residents. Resident identifiers: #27, #111, #38, #4, #105, and #72. Facility census: 115. Findings include: a) Resident #27 Observation, on 08/08/11 at approximately 1:15 p.m., found the humidifier bottle on Resident #27's oxygen concentrator was empty and the oxygen tubing was dated 07/29/11 -- b) Resident #111 Observation, on 08/08/11 at approximately 1:30 p.m., found no date on Resident #111's oxygen tubing or humidifier bottle. -- c) Resident #38 Observation, on 08/08/11 at approximately 1:35 p.m., found the oxygen tubing and humidifier bottle of Resident #38's oxygen concentrator were dated 07/29/11 -- d) Resident #4 Observation, on 08/08/11 at approximately 1:40 p.m., found the humidifier bottle on Resident #4's oxygen concentrator was nearly empty and the tubing was dated 07/29/11. -- e) Resident #105 Observation, on 08/08/11 at approximately 1:45 p.m., found the oxygen tubing and humidifier bottle of Resident #105's oxygen concentrator were dated 07/29/11. -- f) Resident #72 Observation, on 08/08/11 at approximately 1:50 p.m., found the humidifier bottle of Resident #72's oxygen concentrator was empty and the tubing was dated 07/29/11. -- g) Interview with a nurse (Employee #6) and the administrator (Employee #127), on 08/08/11 at 2:00 p.m., revealed the oxygen tubing and humidifier bottles should be changed every week, and they stated these six (6) residents would have theirs changed right away. The administrator reported the employee who typically oversaw changing of the oxygen tubing and humidifier bottles was out on personal leave and was due back tomorrow, and she did not realize the tubing and bottles were not all being changed in her a… | 2015-08-01 |
| 9883 | 9883 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-08-01 | 514 | D | 0 | 1 | EUJZ12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, resident observation, record review, and staff interview, the facility failed to maintain a clinical record that provided accurate information regarding Resident #12's refusal of a treatment. This was found for one (1) of three (3) residents reviewed for implementation of the resident's care plan. Facility census: 116. Resident identifiers: #12. Findings include: a) Resident #12 During a resident observation, on 07/31/13 at 9:22 a.m., Resident #12 was observed sitting at the edge of the bed with his right leg dangling over the side. He was wearing a gown, and only a sock was observed on his right lower extremity. Review of the medical record on 07/31/13 at 9:30 a.m., revealed a readmission nursing assessment dated [DATE]. It noted the resident had returned from the hospital with an unna boot. A physician's orders [REDACTED]. Another observation of the resident on, 07/31/13 at 10:30 a.m., revealed the resident did not have an unna boot on his right lower leg. During the interview, at 10:30 a.m., the Resident #12 said he wanted the unna boot applied. The resident said he needed it so he could walk. (An unna boot is impregnated gauze with zinc oxide and is applied as a wrap.) The resident was informed of the purpose of the wrap and asked again why he was not wearing it. He said it was because the nurse did not apply it. It remained unclear if the resident understood the purpose of the wrap. Review of the treatment administration record (TAR) revealed the unna boot was scheduled for application on Mondays and Thursdays. Resident #12 was noted to have refused the unna boot on the dates of 07/25/13 and 07/29/13. A note on the TAR, dated 07/25/13, indicated the resident did not want the unna boot replaced, stating, "I don't need that thing." It also indicated the resident was educated, but still refused to let the nurse apply the boot. The nurse practitioner (NP) was aware. During an interview with Employee #58, a regi… | 2015-08-01 |
| 9884 | 9884 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-05-10 | 323 | D | 1 | 0 | 1WUS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision to prevent accidents by not following the care plan. A resident with a history of falls with injury, was not provided with mats on both sides of her bed. Additionally, the care plan directed that nothing be place on top of the mats, but an over-bed table was observed on top of the mat. This was found for one (1) of six (6) residents reviewed. Resident identifier: #59. Facility census: 92. Findings include: a) Resident #59 Resident #59 was a [AGE] year old woman admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her medical record was reviewed on 05/07/12 at 3:42 p.m. She was assessed as being at risk for falls on nursing assessments completed on 11/01/11 and 03/13/12. She experienced falls on 01/02/12, in which she suffered a skin tear to her right forearm; two separate falls on 01/13/12, one at 10:45 a.m., in which she suffered a laceration to her forehead, and one at 6:25 p.m. with no apparent injury; on 03/05/12, and 03/12/12, in which she suffered a laceration to her forehead that required transport to the emergency room for treatment. Three (3) of the five (5) falls were the result of the resident rolling out of her bed. Her comprehensive minimum data set (MDS) assessment, of 01/20/12, showed she required extensive assistance of two (2) staff for bed mobility, transfers, and walking. Her current care plan had a focus item for risk for falls and associated injuries. The care plan and the KARDEX, or specific instructions for nursing assistants to guide them in providing appropriate effective individualized care to the residents, both stated she was to have fall mats to both sides of her bed, with nothing placed on top of the fall mats. On 05/07/12 at 2:32 p.m., Resident #59 was observed in bed in her room. There was a f… | 2015-08-01 |
| 9885 | 9885 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-05-10 | 353 | D | 1 | 0 | 1WUS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, review of resident council meeting minutes, record review, resident interview, family interview, and staff interview, the facility failed to maintain adequate staffing levels across all shifts to ensure residents' needs were met by answering call lights in a timely manner and failed to provide needed assistance to dependent residents with eating and other needs. These practices affected more than a limited number of residents. Resident identifiers: #81, #7, #85, #61, #29, #58, #79, and #35. Facility census: 92. Findings include: a) Resident council meeting minutes Review of resident council meeting minutes, on 05/07/12 at 1:00 p.m., found that during the meeting of 04/17/12, it was noted that call lights were not being answered on the 3:00 - 11:00 shift. A review of the facility complaint file, on 05/07/12 at 1:30 p.m. found two (2) complaints regarding call lights. 1) There was a complaint from Resident #81 on 03/07/12, which stated (typed as written): "call bell not being answer. He said it take them 1 hour. Sometimes." 2) There was a complaint from Resident #7, on 04/17/12, which stated (typed as written): "Call lights not being answered in a timely manner on 3 - 11 shift." Under the section of the complaint form "What other action was taken to resolve the concern (be specific)", was recorded "Call light audit is to be completed by staff." On 05/08/12 at 2:30 p.m., an interview was conducted with the director of nursing (DON), Employee #68 regarding the issues voiced and the follow up indicated on the form. She stated there was an issue with call lights. In response to this issue, audits on different shifts and at different times were being conducted by different staff members. A review of these audits revealed an identified issue with call lights on 05/01/12 at 5:58 a.m. The audit found that the call light in room [ROOM NUMBER] was lit at 5:58 a.m., and was not answered until 6:16 a.m., a response time of eighteen… | 2015-08-01 |
| 9886 | 9886 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-05-10 | 364 | E | 1 | 0 | 1WUS11 | . Based on observation, family interview, and staff interview, the facility failed to provide food that was served at temperatures that would enhance the palatability of the foods. This had the potential to affect all residents who take their meals in the dining room. Facility census: 92. Findings include: a) The daughter and medical power of attorney (MPOA) of Resident #47, was interviewed in the facility on 05/07/12 at 3:20 p.m. She said the food was always cold when the residents were served in the dining room at lunch. The trays were all placed in an open cart and placed in the dining room for staff to serve to residents. By the time they got it, the food was cold. b) Observations were conducted during the luncheon meal in the main dining room on 05/08/12 and 05/09/12. On 05/08/12 at 11:32 a.m., there were three (3) staff present in the dining room. Prepared trays were stacked in an open metal frame cart in the dining room. Over the next twenty-three (23) minutes, additional staff presented to the dining room until there were eight (8) staff serving and assisting residents. At 11:55 a.m., there were four (4) remaining trays to be served. The dietary manager, Employee #51, was asked to obtain another tray for Resident #6 and to take the temperature of the items on the tray on the cart for serving. The temperatures were as follows: Broccoli: 110 degrees Fahrenheit Hot meat sandwich: 104 degrees Fahrenheit Potatoes: 111 degrees Fahrenheit Coffee: 114 degrees Fahrenheit Milk: 56 degrees Fahrenheit. The commonly accepted temperature for hot foods at the point of service is a minimum of 120 degrees Fahrenheit, and cold foods should not be above 50 degrees Fahrenheit. The dietary manager, Employee #51, confirmed the temperatures. She pointed out there was a microwave available in the dining room for reheating trays, but acknowledged that no staff had done so while she was in the room. . | 2015-08-01 |
| 9887 | 9887 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-01-08 | 514 | E | 1 | 0 | 0RE212 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure accurate documentation for seven (7) of thirteen (13) residents who required bed and/or chair alarms for safety precautions. These residents had no directives on the Treatment Administration Records (TAR) to check the functionality of the alarms. Instead, the TAR directed that alarms were to be used, or nurses "may utilize"alarms. This had the potential to endanger those seven (7) residents by not ensuring clear directives to nursing staff to check and document the functionality of the alarm equipment. Resident identifiers: #55, #18, #35, #85, #62, #26, and #32. Facility census: 87. Findings include: a) Resident #55 An incident and accident report was reviewed on 01/08/14 at 12:00 p.m. This review revealed that on 01/04/14 at 7:45 a.m., Resident #55 was found on the floor by staff. The resident had removed her alarm prior to the fall. The report did not indicate whether it was alarming at or before the time of the fall. Another incident report, dated 01/04/14 at 9:00 a.m., revealed she was again discovered by staff lying on the floor beside her bed. According to the incident report, the alarm did not sound. Staff replaced the alarm at that time. The treatment administration record (TAR) was reviewed on on 01/08/14 at 1:00 p.m.. It directed that staff "may utilize sensor pad alarm to bed at al limes, to alert staff to resident's attempts to transfer unassisted, to minimize falls risk". The start date for this intervention was 12/24/13. Nurses initialed the TAR at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. An interview was conducted with licensed nurse Employee #44 at 1:30 p.m. on 01/08/14. She first checked the TAR, then said there is no order on the TAR for staff to check the functionality of the bed alarm. She said there was someone assigned to check the functionality via daily audits. On 01/08/14 at 1:45 p.m., the administrator was asked… | 2015-08-01 |
| 9888 | 9888 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-11-06 | 252 | E | 0 | 1 | K1XR12 | . Based on observation and staff interview, the facility failed to ensure a homelike environment which de-emphasized the institutional character of the setting. The facility was not free, to the extent possible, of unpleasant odors. Urine odors from the laundry, odor of urine from a recognized resident source, and the odor of permanents from the beauty shop lingered and/or reoccurred throughout Hilltop unit. The facility had a cover-up deodorizer to use after the odors occurred; however, staff did not always use the deodorizer when needed. There was no evidence the facility attempted a preventative solution to eliminate the known odors. This had the potential to effect all (46) residents residing on Hilltop unit. Facility census: 83. Findings include: a) At 9:30 a.m. on 11/05/14, a strong odor of urine was noticed coming from room #149. It could be smelled beyond the nurses station at the end of the hall. Employee #91, a licensed practical nurse (LPN) stated a resident who resided in that room had become agitated and refused to allow staff to change her brief. She said this happened often and they would try again later. At 11:30 a.m., the strong urine odor was still present and could be detected throughout Hilltop hall, including the Solarium. The odor was present outside the main dining room, which was filling with residents for the noon meal, and became stronger at the entry to Hilltop hall. The Administrator (NHA) was approached in her office, at 11:30 a.m. on 11/05/14. She was told of the odor, and was asked what was done to dispel odors in the facility. The NHA immediately said she thought the odor was coming from the laundry. She added that there were odors into the hall from the laundry at times, and she went to check. The laundry was located between the dining room and Hilltop hall. The NHA returned and acknowledged the odor was from the laundry. She said she did not know know what had been done to dispel it. The NHA stated she would refer the answer to the housekeeping supervisor (Employee #59) when he r… | 2015-08-01 |
| 9889 | 9889 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-11-06 | 502 | D | 0 | 1 | K1XR12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure a physician ordered laboratory (lab) test for one (1) of twenty-one (21) sample residents was obtained. Resident identifier: #101. Facility census: 83 Findings include: a) Resident #101 Review of medical records, on 11/05/14 at 10:45 a.m., revealed Resident #101 had a physician's orders [REDACTED]. A lab result, dated 09/09/14 revealed the Vitamin D level was completed with a value of 17.84 ng/ml (nanograms per milliliter). The lab results also noted the level for Vitamin D (25-OH) by many experts was recommended to be greater than 30 ng/ml. The ordering physician signed the lab results and wrote a note for the lab to be repeated in thirty (30) days, which would have been during the first full week of October 2014. On 11/05/14 at 1:30 p.m., upon inquiry, the director of nursing stated there was no evidence the repeat lab value had been completed. . | 2015-08-01 |
| 9890 | 9890 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-08-25 | 278 | D | 0 | 1 | MZQB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure minimum data set assessments (MDSs) accurately reflected the health and functional status of two (2) of fourteen (14) sampled records. Resident identifiers: #141 and #21. Facility census: 140. Findings include: a) Resident #141 Record review revealed Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's discharge MDS, with assessment reference date (ARD) of 08/04/11, found the assessor noted the number of falls since the prior assessment (which was a quarterly MDS with an ARD of 07/13/11) as follows: - Fall with no injury - none - Fall with injury (except major) - none - Fall with major injury - 1 - A review of the incident reports, nursing notes, and the significant event reporting in the computer revealed that Resident #141 had sustained falls as follows: - On 07/20/11 at 5:00 p.m., he was found on the floor and had sustained a scratch to his right hand measuring approximately 5 cm long. - On 07/22/11 at 7:30 p.m., he slid down the side of a chair after missing the seat, and an assessment found no apparent injuries. - On 07/24/11 at 10:45 a.m., he fell , hitting his left arm and the left side of his head against a door frame; he subsequently was found to have sustained a fractured humerus and a subdural hematoma. - The above assessment was inaccurate with respect to the numbers and types of falls that had occurred since his prior MDS with an ARD of 07/13/11. -- b) Resident #21 A review of a significant change in status MDS with an ARD of 05/02/11 found the assessor indicated, in Item M0300F, that Resident #21 had one (1) unstageable pressure ulcer. In a quarterly MDS with ARD of 07/27/11, the assessor again indicated the presence of one (1) unstageable pressure ulcer (measuring 0.4 cm x 0.5 cm) in Item M0300F. - Review of the resident's nursing notes revealed an entry, at 9:50 a.m. on 06/21/11, stating: "Note necrotic tissue to L (l… | 2015-08-01 |
| 9891 | 9891 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-08-25 | 513 | D | 0 | 1 | MZQB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain in a timely manner and file on the medical record the results of diagnostic services performed on one (1) of fourteen (14) sampled residents. The results of diagnostic procedures performed to evaluate Resident #33's urinary tract were not obtained and filed on the resident's medical record until thirteen (13) days after the procedures were completed. Resident identifier: #33. Facility census: 140. Findings include: a) Resident #33 Medical record review, on 08/22/11, revealed this [AGE] year old male with [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder had an indwelling Foley urinary catheter in place for a long time. He also had experienced a history of urinary tract infections and [MEDICAL CONDITION]. Resident #33 had a history of [REDACTED]. Further medical record review revealed the resident, at a local hospital on [DATE], underwent a rigid cystourethroscopy (endoscopy of the urinary bladder via the urethra, carried out with a cystoscope). The resident also had a bilateral retrograde pyelography with interpretation (a procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney). These tests revealed no evidence of hydrouretero[DIAGNOSES REDACTED] (distension of the kidney and/or ureter caused by backward pressure on the kidney when the flow of urine is obstructed). (http://www.merckmanuals.com/home/kidney_and_urinary_tract_disorders/obstruction_of_the_urinary_tract/hydro[DIAGNOSES REDACTED].html#v 1) - When asked about the results of the above mentioned diagnostic procedures on 08/22/11 at 12:00 p.m., Employee #200 (a registered nurse) reported the facility had not yet received the report. She said she had this on a list of items she needed to get. On 08/23/11 at approximately 10:00 a.m., the facility obtained a copy of the diagnostic test results. - Review of the operative report for these two (2) procedur… | 2015-08-01 |
| 9892 | 9892 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-08-25 | 224 | G | 0 | 1 | MZQB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, review of facility policies and clinical services notices, and staff interview, the facility failed to provide care and services necessary to avoid physical harm for 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 occurred, staff did not follow facility policy, by not moving the resident until he was examined by emergency personnel or a head injury was ruled out. Although a neurological evaluation form was initiated for this fall, the assessments recorded were not complete / accurate (e.g., several entries identified limitations in motor movement to the wrong limb), and times were not always recorded; as a result, it could not be verified that these neuro checks were being completed at progressive intervals as specified in the directions on the form. 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. On [DATE], prior to the resident leaving the facility for an outpatient appointment with an orthopedist, the nurse was notifie… | 2015-08-01 |
| 9893 | 9893 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-05-10 | 225 | G | 1 | 0 | DT7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, staff interview, review of police reports, policy review, and resident interview, the facility failed to report and conduct a thorough investigation following allegations of verbal abuse by a nursing assistant (NA) toward one (1) of four (4) sampled residents. Resident identifier: #29. Facility census: 122. Findings include: a) Resident #29 1) Review of facility documents found an NA, Employee #9, alleged he witnessed sexual abuse/assault between Resident #29 and a male blood relative on [DATE], at approximately 4:00 p.m. The documents contained a signed statement by a registered nurse, Employee #145, which stated Employee #9 reported the allegation to her on [DATE]. An interview was conducted with Employee #145, on [DATE] at 4:15 p.m. Employee #145 described the events of [DATE]. She stated Employee #9 reported the allegation to her just as the fire alarm went off. Employee #145 stated she reported the allegation after the fire drill was over. An interview with the maintenance director, Employee #87, on [DATE] at 3:15 p.m., verified a fire drill was conducted between the hours of 4:00 p.m. and 4:20 p.m. on [DATE]. He provided a record of the [DATE] fire drill. Review of a statement signed by the social worker, Employee #101, on [DATE], found Employee #145 reported the allegation to her at 4:45 p.m. on [DATE]. The statement noted Employee #101 entered the resident's room, at 4:30 p.m. on [DATE], to complete readmission paperwork and "everything seemed fine.". Employee #101 was interviewed on [DATE] at 11:40 a.m. She confirmed the allegation of sexual abuse/assault was reported to her after the fire drill. Review of the police report, obtained on [DATE], found Employee #9 alleged he witnessed a male blood relative commit an oral intrusion upon Resident #29, at 3:50 p.m. on [DATE], when he answered the call light to remove Resident #29 from the bedpan. The report stated Employee #9 cleaned the resident, … | 2015-08-01 |
| 9894 | 9894 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-05-10 | 280 | D | 1 | 0 | DT7O11 | . Based on family interview, medical record review, and staff interview, the facility denied a family member the right to participate in the development of a comprehensive care plan for one (1) of four (4) sampled residents. Resident identifier: #29. Facility census: 122. Findings include: a) Resident #29 An interview was conducted with Resident #29's daughter (Family Member #1) on 05/01/12 at 8:30 p.m. Family member #1 relayed she had been denied the right to participate in a meeting to discuss her mother's care. Review of the medical record found a social services note authored by Employee #101 on 04/18/12 at 3:28 p.m. The note written by Employee #101 stated the daughter was informed that medical issues could only be discussed with a medical power of attorney (MPOA) and the meeting would have to be rescheduled. The medical record contained a combined MPOA and living will document, signed, witnessed, and notarized on 03/16/09 naming this daughter as successor MPOA. . | 2015-08-01 |
| 9895 | 9895 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-05-10 | 323 | E | 1 | 0 | DT7O11 | . Based on observation, staff interview, and medical cart inventory, the facility failed to ensure the resident environment was as free of accident hazards as possible. A nursing staff member left two (2) stocked medication carts containing routine and stock medications, insulin syringes, lancets, and a hawkbill knife unlocked and unsupervised in the resident hallway. This practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 122. Findings include: a) During random observations of the resident environment on the C hall of the facility, on 05/01/02 at 4:15 p.m., two (2) medication carts were present in the resident hallway with no visible staff members in attendance. A closer inspection of the carts noted that the locking mechanisms on both carts were not engaged. Resident #99 was seated in a wheelchair approximately 4 (four) feet from the medication carts. Licensed practical nurse, Employee #113, exited a resident's room across the hallway after attending to a resident. Her back was toward the hallway. The observation was reported to two (2) registered nurses, Employees #145 and #91. An inventory of the medication carts, conducted in the presence of the nurses, found the carts contained drawers of routine and stock medications, lancets and insulin syringes. Additionally, the cart sitting on the left contained a hawkbill knife in the top drawer. An interview with Employee #145 confirmed it was never acceptable to leave medication carts unlocked and unsupervised. . . | 2015-08-01 |
| 9896 | 9896 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-06-21 | 166 | D | 1 | 0 | MNCH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility complaint files, family interview, review of facility complaint policy, medical record review, and staff interview, the facility failed to ensure one (1) of five (5) sampled residents was afforded the right to prompt efforts by the facility to resolve grievances. Resident #92 experienced a possible allergic or toxic reaction to cleaning materials causing respiratory [MEDICAL CONDITION] with subsequent intubation and placement on a ventilator. The resident's spouse complained to the head of housekeeping services, Employee #153, concerning the use of fabric freshener on her husband's bedside curtains. Employee #153 failed to comply with facility policy related to voiced concerns in order to resolve the spouses concerns. Resident identifier: #92. Facility census: 117. Findings include: a) Resident #92 An interview was conducted with the spouse of Resident #92 on 06/21/12 at 2:00 p.m. in the resident's room. She stated a member of housekeeping staff (Employee #64) sprayed deodorizer on her husband's bedside curtains on 05/16/12. She stated her husband was allergic to the spray and he got so sick he wound up on the hospital on a ventilator. She stated she complained to the head of housekeeping, Employee #153, about spraying deodorizer on the curtains in her husband's room and asked him to place a sign in the room to keep housekeeping staff from using the deodorizer. She stated Employee #153 refused to place a sign in the room and housekeeping staff were still spraying her husband's bedside curtains. Review of the medical record found an emergency department evaluation dated 05/21/12. According to the document, Resident #92 was intubated and placed on a respirator in the emergency department on 05/21/12 with [DIAGNOSES REDACTED]. Review of the facility's complaint file, on the afternoon of 06/21/12, found no record of a complaint related to Resident #92. An interview with housekeeping aide, Employee #62, was conducted … | 2015-08-01 |
| 9897 | 9897 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-06-21 | 225 | D | 1 | 0 | MNCH11 | . Based on review of facility documents and staff interview, the facility failed to ensure an allegation of neglect involving one (1) of one hundred-seventeen (117) residents was reported and investigated in accordance with these requirements. Resident #86 required supervision during meals. She was left unsupervised in her room where she "choked" on her lunch. Resident identifier: #86. Facility census: 117. Findings include: a) Resident #86 A review of the facility's complaint files, on the afternoon of 06/21/12, found a facility concern form dated 05/23/12. The form documented Resident #86 was not supposed to eat by herself. She "got choked on her lunch" and her roommate got the social worker who got nursing assistants to render assistance to the resident.. There was no evidence this allegation of neglect was reported in accordance with State law. Registered nurse, Employee #117, was interviewed on 06/21/12 at 6:20 p.m. He stated the resident was supposed to be cued to swallow twice after each bite of food or drink of liquid. He stated an inservice was provided to direct care staff to provide supervision during the entire meal following the incident. An interview with the director of nursing (DON), Employee #10, on 06/21/12, at approximately 6:30 p.m., confirmed this allegation of neglect was not reported as required. . | 2015-08-01 |
| 9898 | 9898 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-06-21 | 280 | D | 1 | 0 | MNCH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, the facility failed to revise the care plan to meet the needs of one (1) of five (5) sampled residents. Resident #92 was hospitalized , intubated, and placed on a respirator due to a possible allergic or toxic reaction to cleaning materials causing respiratory [MEDICAL CONDITION]. The facility failed to revise the care plan to reflect this potential complication related to chemical products. Resident identifier: #92. Facility census: 117. Findings include: a) Resident #92 During an interview with the spouse of this incapacited resident, on 06/21/12 at 2:00 p.m., she stated housekeeping staff sprayed deodorizer on her husband's bedside curtains and made him so sick he was put in the hospital on a ventilator. Review of the medical record found the resident was hosptalized on [DATE] with [DIAGNOSES REDACTED]. The resident was intubated and placed on a ventilator. He was readmitted to the facility on [DATE]. Review of the current care plan, with a target date of 09/12/12, noted no interventions to refrain from utilizing cleaning or deodorizing chemicals in Resident #92's room. The minimum data set (MDS) nursing staff, Employee #47 and Employee #36 were interviewed on 06/21/12 at 3:45 p.m. Employee #36 stated she was aware of the emergency department report documenting a possible allergic or toxic reaction to cleaning materials causing respiratory [MEDICAL CONDITION]. She reviewed the care plan related to the resident's risk for respiratory impairment due to [DIAGNOSES REDACTED]. The goals developed included, "Will experience effective symptom management". MDS nurse, Employee #36 was asked why, if she was aware of the emergency department report, the care plan did not include interventions to prevent staff from utilizing these products in the resident's room. Employee #36 stated she was only responsible for scheduled care plans. She stated if something happens between those t… | 2015-08-01 |
| 9899 | 9899 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-06-21 | 323 | D | 1 | 0 | MNCH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, staff interview, and medical record review, the facility failed to ensure the environment remained free from environmental hazards which potentially caused a severe respiratory reaction in one (1) of five (5) sampled residents. Resident #92 was intubated and placed on a respirator with one of the emergency physician's impression being "Possible allergic or toxic reaction to cleaning materials causing respiratory edema". The facility failed to ensure housekeeping staff were instructed to refrain from spraying chemical deodorizers in the resident's room. Resident identifier: #92. Facility census: 117. Findings include: a) Resident #92 During an interview with the spouse of this incapacitated resident, on 06/21/12 at 2:00 p.m., she stated housekeeping staff sprayed deodorizer on her husband's bedside curtains and made him so sick he was put in the hospital on a ventilator. Review of the medical record found the resident was hosptalized on [DATE] with [DIAGNOSES REDACTED]. The resident was intubated and placed on a ventilator. He was readmitted to the facility on [DATE]. An interview with housekeeping aide, Employee #62, was conducted at 2:30 p.m. on 06/21/12. He was pushing a housekeeping cart up the 100 hallway. He verified he worked for housekeeping and had worked in that position for approximately 2 years. He was asked if there was deodorizer on the housekeeping cart for use in the resident rooms. He opened the door of the cart and indicated a spray bottle labeled "fabric freshener". When asked if he had been instructed to not use the spray in rooms of residents with breathing problems, he stated he had not been instructed to not use it. An interview was conducted with Employee #153 on 06/21/12 at 2:45 p.m. He stated he had been the head of housekeeping for 1 year and supervised about eight (8) housekeeping staff members. According to Employee #153, the facility had switched to a fabric freshener spray to get away… | 2015-08-01 |
| 9900 | 9900 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-06-21 | 502 | D | 1 | 0 | MNCH11 | **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 to meet the needs of one (1) of five (5) sampled residents. Resident identifier: #92. Facility census: 117. Findings include: a) Resident #92 Review of the medical record found Resident #92 was readmitted to the facility on [DATE] following an acute care stay. Review of the hospital discharge summary found the resident was to have a basic metabolic panel (BMP) in one (1) week. Review of the facility admission orders [REDACTED]. The medical record contained no evidence the facility had obtained this ordered laboratory service. An interview with the director of nursing (DON), Employee #10, on the afternoon of 06/21/12, confirmed the facility did not obtain the ordered laboratory test. . | 2015-08-01 |
| 9901 | 9901 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-05-30 | 203 | D | 1 | 0 | 0XPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide written information to the resident or family member or legal representative, regarding the agencies with which complaints or appeals might be made. This was evident for two (2) of six (6) sampled residents. Resident identifiers: #127 and #107. Facility census: 125. Findings include: a) Resident #127 Record review found that Resident #127 was discharged from the facility to an acute care hospital on [DATE]. Record review found no evidence of a transfer sheet that was given to this resident at the time of discharge, listing entities where appeals or concerns may be communicated. b) Resident #107 Record review found that Resident #107 was discharged from the facility to an acute care hospital on [DATE]. No evidence was found of the resident being provided with a list of agencies with which an appeal or concern might be filed. During interview with the Director of Nursing on 05/30/12 at 2:45 p.m., she was unable to find the transfer sheet for this resident's transfer. . | 2015-08-01 |
| 9902 | 9902 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-05-30 | 205 | D | 1 | 0 | 0XPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide written information, to the resident or family member or legal representative, of the nursing facility's policies regarding bed-hold periods at the time of transfer. This was evident for three (3) of six (6) sampled residents. Resident identifiers: #129, #127, and #107. Facility census: 125. Findings include: a) Resident #129 Record review found Resident #129 was discharged from the facility to an acute care hospital on [DATE]. Further record review found no evidence of a bed hold notice given to this resident at the time of discharge, or within the first 24 hours. b) Resident #127 Record review found that Resident #127 was discharged from the facility to an acute care hospital on [DATE]. Record review found no evidence of a bed hold notice that was given to this resident at the time of discharge, or within the first 24 hours. c) Resident #107 Record review found that Resident #107 was discharged from the facility to an acute care hospital on [DATE]. Further record review found no evidence of a bed hold notice that was given to this resident at the time of discharge, or within the first 24 hours. d) During interview with the Director of Nursing on 05/30/12 at 2:45 p.m., she stated it was not necessary to give a bed hold notice when the census was less than 90% occupancy. She said the facility was licensed for 184 residents, but had only 124 beds occupied. . | 2015-08-01 |
| 9903 | 9903 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-05-30 | 514 | C | 1 | 0 | 0XPG11 | Based on record review, staff interview, and policy review, the facility failed to maintain clinical records to show that residents received safe and orderly transfer from the facility, with pertinent communication to the receiving facility and to the resident. Facility policy dictated necessary items to be sent with the resident at the time of discharge, but record review found no evidence of what, if any, portions of the clinical records were sent with the resident when he or she was transferred to an acute care facility. This was evident for three (3) of six (6) sampled residents. Resident identifiers: #129, #127, #107. Facility census: 125. Findings include: a) Resident #129 Review of the "Acute Care Transfer Document Checklist" provided by the Director of Nursing (DON) on 05/29/12 at approximately 12:50 p.m., found that seven (7) documents should "always" accompany the resident when transferred. These items were the resident transfer form, face sheet, current medication list or current MAR (Medication Administration Record), advance directives, care limiting orders, out of hospital DNR (do not resuscitate), and the bed hold policy. Additionally, there was another section with directives to send other documents if indicated. This included the Nurse's Progress Note, the most recent history and physical, and any recent hospital discharge summary, recent orders related to acute condition, relevant lab results, relevant x-rays, and personal belongings sent with the resident (eyeglasses, hearing aid, dental appliance, or other items). Review of the acute care transfer document checklist form, also found there were lines beside each of the above listed items, and directives to check all that applied. During interview with the DON, on 05/30/12 at 1:00 p.m., she said they do not mark this form; rather, it is their policy of what to send, and is used a as guide. When asked if staff document in the nurses' notes what they send, or any kind of documentation of what they send, she stated probably not. She acknowledged th… | 2015-08-01 |
| 9904 | 9904 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-07-22 | 492 | D | 0 | 1 | UNLT12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and a review of the West Virginia Board of Pharmacy, West Virginia Code of State Rules, the facility failed to comply with the rules set forth by the board of pharmacy related to labeling of medication for one (1) of eight (8) sampled residents. Resident identifier: #21. Facility census: 58. Findings include: a) Resident #21 On 07/21/11 at approximately 2:00 p.m., the medical record for Resident #21 revealed a physician's orders [REDACTED].) The order, written at 10:00 p.m. on 07/15/11, stated: "(symbol for 'change') [MEDICATION NAME] to 66 ml BID (twice per day)." The Medication Administration Record [REDACTED]. On 07/22/11 at approximately 3:00 p.m., Employee #76 (registered nurse / nurse practice educator) and Employee #77 (a corporate registered nurse) provided a copy of the label attached to the bottle of [MEDICATION NAME]. The label contained the resident's name as well as the date "07/14/11". The label indicated the following dosage instructions: 22.5 ml by mouth every eight (8) hours. The bottle also identified the contents of the medication as [MEDICATION NAME] 10 gm/15 ml solution. The West Virginia Board of Pharmacy, West Virginia Code of State Rules, states: "19.13.2. To dispense, deliver, or distribute a prescription drug order accurately as prescribed. For the purposes of this paragraph 'accurately as prescribed' means a. To the correct patient (or agent of the patient) for whom the drug or devise was prescribed; b. with the correct drug in the correct strength, quantity, and dosage from ordered by the practitioner; a pharmacist may substitute a generic drug pursuant to W.Va. Code? 30-5-12b; and c. With correct labeling (including directions for use) as ordered by the practitioner. ..." On 07/22/11 at approximately 3:30 p.m., Employees #76 and #77 confirmed the label on the bottle of [MEDICATION NAME] did not accurately reflect the current order by the prescribing practitioner. . | 2015-08-01 |
| 9905 | 9905 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2012-07-26 | 514 | B | 1 | 0 | U0Q511 | . Based on observation, review of documentation of shower/bath administration forms, interviews with residents, and interviews with staff, it was determined staff had not completed ADL (activity of daily living) flow sheets to show that baths/showers were consistently given. There were many blanks and incomplete documentation on these forms for residents on two (2) of four (4) hallways. Hallways involved: 200 and 300. Census: 62. Findings include: a) A review of bath and shower records on the morning of 07/26/12 revealed there were many records that contained numerous blanks and inconsistent documentation on whether baths/showers were given or not. Discussion with the director of nursing, Employee #72, at the time indicated, verified better documentation should be implemented that would verify the baths were given as needed. A short while later, Employee #72 returned and explained that after further review, the problem with documentation of baths for residents was on the 200 and 300 hallways. By observations of residents, staff interviews, and resident interviews, it was determined that baths were being given and it was a documentation issue as opposed to the baths not being provided. Residents expressed they received their baths on time. Staff interviews revealed that they were able to get the showers done for the residents on their assignment as required. No odors or grooming issues were noted when doing observations of residents. . | 2015-08-01 |
| 9906 | 9906 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2012-06-20 | 323 | G | 1 | 0 | TFDT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide a safe environment for a resident who was newly admitted and had been identified as having repeated falls just prior to coming to this facility. It was identified Resident #67 required the assistance of two (2) staff members for transfers and toileting assistance. This resident had a recent CVA (cerebral vascular accident) and suffered from left hemi-paresis. She was noted to have experienced some periods of confusion, memory impairment problems, impaired balance, she had functional limitations of her entire left side, she was impulsive, and had a history of [REDACTED]. This resident was left unsupervised sitting on the toilet in the bathroom alone. She fell from the commode sustaining multiple left-sided facial fractures and subsequent hospitalization . Actual harm was identified for one (1) of nine ((9) sampled residents. Resident identifier: #67. Facility Census: 65. Findings include: a) Resident # 67 This resident was admitted to the facility on [DATE] from another nursing home. Documents were provided from the transferring facility to the receiving facility about her status at the transferring facility, including information she had fallen two (2) times in the two (2) weeks prior to her transfer. Her recapitulation of stay from the prior facility stated under the section titled "Rehabilitation services" that the resident "continues to remain impulsive with behaviors thinking she can walk independently. Currently walking with max (maximum) assist of two." The day the resident was admitted to this facility, her admission nursing assessment indicated in Section twelve (12) that she had range of motion impairments on one side that interfered with daily functions or placed the resident at risk for injury. This section was also coded that she was not steady and only able to stabilize with human assistance for moving from seated to standing position, walking, moving on… | 2015-08-01 |
| 9907 | 9907 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2012-06-18 | 157 | D | 1 | 0 | HT0511 | . Based on record review and staff interview, the facility did not ensure that a resident's legal representative was notified timely of a change in condition. Resident #61 had a fall with injuries. After an initial unsuccessful attempt to contact the responsible party, no further attempts were made until the resident was transferred to the hospital. One (1) of a sample of five (5) residents was affected. Facility census: 60. Findings include: a) Resident #61 Nursing documentation, on 06/03/12 at 4:00 a.m., indicated the resident had a fall with injuries. The resident was noted to have sustained skin tears and a hematoma to the right side of the forehead. The physician was notified at 4:15 a.m. and ordered neuro checks according to facility policies. At 8:00 a.m., a nursing note indicated, an attempt was made to notify the resident's legal representative of the resident's fall. No further documentation was found to support the facility had continued to try to notify the the resident's legal representative of the fall with injuries. A nursing note, on 06/03/12 at 7:45 p.m., indicated the resident was transferred to the hospital and the legal representative was notified of the transfer. . | 2015-08-01 |
| 9908 | 9908 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2010-08-05 | 250 | D | 0 | 1 | 2XEX12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted by the facility to the State survey agency following the survey team's exit conference, the facility failed to provide medically-related social services by failing to develop and implement a discharge plan to ensure a safe and orderly discharge from the facility. This was found for one (1) of five (5) residents whose closed records were reviewed. Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, "...Because of her moderate dementia and alcohol dependence she was given Valium to prevent withdrawal. ..." Also on page 2 was stated, "Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time." (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: "5. Activity is ambulation with assist and a walker." A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under "A/P" ("assessment" and "plan"): "5. Alcohol dependence: Abstain from future use ...." - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both… | 2015-08-01 |
| 9909 | 9909 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2010-08-05 | 203 | D | 0 | 1 | 2XEX12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted to the State survey agency following the survey team's exit conference, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to provide a written notice of transfer or discharge (to include the reasons for the move and a notice of the right to appeal this action to the State) to the resident's legal representative at least thirty (30) days before the resident was transferred or discharged . Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. The resident's closed record contained no evidence that a written notice of transfer or discharge was provided by the facility to the resident's legal representative at least thirty (30) days before the resident was moved, to include the reasons for the transfer / discharge and a notice of the right to appeal this action to the State. - 2. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for … | 2015-08-01 |
| 9910 | 9910 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2010-08-05 | 204 | D | 0 | 1 | 2XEX12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, and review of information provided by the facility to the State survey agency after the survey team's exit, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to take steps within its control to ensure a safe and orderly discharge of Resident #57 from the nursing facility to a legally unlicensed care home. Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, "...Because of her moderate dementia and alcohol dependence she was given [MEDICATION NAME] to prevent withdrawal. ..." Also on page 2 was stated, "Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time." (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: "5. Activity is ambulation with assist and a walker." A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under "A/P" ("assessment" and "plan"): "5. Alcohol dependence: Abstain from future use ...." - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented … | 2015-08-01 |
| 9911 | 9911 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2010-08-05 | 284 | D | 0 | 1 | 2XEX12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted by the facility to the State survey agency following the survey team's exit conference, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to develop a post-discharge plan of care that accurately and completely identified and communicated to the resident's family and receiving facility the care and services the resident would require in order to ensure a safe and orderly discharge. The discharge transition plan developed by the nursing facility for Resident #57 failed to communicate significant information about the resident's medical history (including a recent history of alcohol dependence) and current health status, failed to identify the need for home health services and occupational therapy as ordered by the physician, and failed to accurately communicate the need for such things as diet modifications and special equipment. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, "...Because of her moderate dementia and alcohol dependence she was given [MEDICATION NAME] to prevent withdrawal. ..." Also on page 2 was stated, "Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this tim… | 2015-08-01 |
| 9912 | 9912 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2010-08-05 | 325 | D | 0 | 1 | 2XEX12 | **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 fifteen (15) sampled residents, to ensure the resident received appropriate treatment and services to maintain acceptable parameters of nutritional status, by failing to ensure all direct care staff was aware of interventions identified by the rehabilitative therapy staff to reduce distractions during meal times and promote good oral intake. Resident identifier: #3. Facility census: 54. Findings include: a) Resident #3 1. Medical record review, on 08/04/10, revealed Resident #3 was admitted to the facility on [DATE]. On 10/28/08, the facility first identified she was at risk for decreased nutritional intake. On 06/10/10, she exhibited swallowing difficulties; the speech-language pathologist (SLP) assessed her and identified she needed a mechanical soft diet with ground meats. Resident #3 began receiving speech therapy (ST) and occupational therapy (OT) to address her decreased nutritional intake and promote self-feeding. Review of Resident #3's weight records revealed she weighed 194# on 05/19/10, weighed 188# on 06/09/10, and weighed 186# on 07/12/10. This represented an 8# weight loss in two (2) months. - 2. Review of the OT progress notes found the following entries: On 06/15/10 - "Pt (patient) seen for lunch meal, removed distracting items like butter knife and food ticket and pushed resident closer to table. Pt also sitting at same table but on opposite side away from distractions of dining room." On 06/16/10 - "Pt seen for lunch meal, provided a bright red place mat to define eating space, removed distracting items." On 06/17/10 - "Pt seen for breakfast meal, removed distracting items and cued patient to initiate meal (sic) pt complies. Discussed / educated present CNA (certified nursing assistant) staff on approaching patient, cueing patient and items to remove. Inservice completed to kitchen staff (servers, etc.) regarding patient (approaching pa… | 2015-08-01 |
| 9913 | 9913 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-06-08 | 157 | D | 1 | 0 | D9VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the treating physician was notified when nursing staff members were unable to administer ordered intravenous therapy for fluid replacement purposes. One (1) of six (6) sampled residents was affected. Resident identifier: #202. Facility census: 123. Findings include: a) Resident #202 Review of the medical record found the resident was admitted to the facility on [DATE] for treatment of [REDACTED]. The resident was determined to lack the capacity to make medical decisions by the treating physician on 04/25/12, with adult protective services (APS) appointed as the resident's health care surrogate. On 05/10/12, laboratory results were positive for a [MEDICAL CONDITIONS] infection. The resident was ordered and began receiving [MEDICATION NAME] 500 mg three (3) times a day (tid) on 05/10/12. The nursing notes documented loose, thin, liquid stools on 05/10/12, 05/11/12, 05/12/12, 05/13/ 12, and 05/14/12. treatment for [REDACTED]. On 05/14/12, the resident was visited by the nurse practitioner who documented the resident to be lethargic and hypotensive. The nurse practitioner ordered 2000 cc normal saline intravenous (IV) fluids on 05/14/12. The order, written at 10:20 a.m. on 05/14/12, specified a bolus of 1000 cc of normal saline for the first liter, then 85 cc/hr for the second liter of fluids. Review of the nursing notes found IV access was was obtained at 12:23 p.m. for administration of the first bolus liter of normal saline. Further review of the nursing notes found a note written at 2:07 a.m. 05/15/12, which documented, "Attempted IV access X 2 which was unsuccessful...". The medical record contained no documentation of what circumstances prompted nursing to again attempt IV access. A late entry note, by the nurse practitioner on 05/15/12, documented "nursing reports pulled out IV, received 900 ml of normal saline". The medical record contained no evidence the… | 2015-08-01 |
| 9914 | 9914 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-06-08 | 246 | D | 1 | 0 | D9VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, resident interview, observation, staff interview, and medical record review, the facility failed to obtain necessary equipment which would enable one (1) of six (6) sampled residents to safely occupy and utilize a wheelchair. Resident #124 was confined to his bed for approximately five (5) days when the seatbelt on his wheelchair malfunctioned. The facility did not obtain a replacement seatbelt in a timely manner to enable this resident to be out of bed. Resident identifier: #124. Facility census: 123. Findings include: a) Resident #124 A family interview was conducted with Resident #124's spouse on 06/05/12 at 1:50 p.m. The resident's spouse stated the resident had been confined to his bed for approximately five (5) days due to the seatbelt on his wheelchair being broken. She stated staff refused to get him up without the seatbelt for fear of the resident falling from his chair. She stated she had asked staff that day to get him up and no one had attempted to assist her husband to his chair. She stated someone was supposed to order a replacement seatbelt last week, but no one appeared to know about the replacement belt being ordered. It was noted Resident #124 was awake, alert, and appeared aware of his surroundings. The resident's spouse stated the resident enjoyed getting out of bed and visiting with her. An interview with Resident #124's alert and oriented roommate confirmed that the resident's seatbelt had been broken and he had not been allowed out of the bed for days. Observation of Resident #124's wheelchair noted the buckle of the seatbelt attached to his wheelchair was broken. An interview was conducted with the licensed practical nurse (LPN), Employee #98, at 2:10 p.m. She verified she was the nurse assigned to the resident and agreed that the resident's spouse had asked her to get the resident up before lunch. Employee #98 stated the resident could not get up due to the seatbelt in his chair being brok… | 2015-08-01 |
| 9915 | 9915 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-06-08 | 327 | G | 1 | 0 | D9VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents received sufficient fluid intake to maintain proper hydration. Resident #202 suffered from a [MEDICAL CONDITIONS] infection with multiple watery stools and an inadequate intake of fluids necessary to maintain health. Additionally, nursing staff members failed to ensure intravenous (IV) fluids were administered in accordance with physician's orders [REDACTED]. Resident identifier: #202. Facility census: 123. Findings include: a) Resident #202 Review of the medical record found the resident was admitted to the facility on [DATE] for treatment of [REDACTED]. The resident was determined to lack the capacity to make medical decisions by the treating physician on 04/25/12 with adult protective services (APS) appointed as the resident's health care surrogate. On 05/10/12, laboratory results were positive for a [MEDICAL CONDITIONS] infection. The resident was ordered, and began receiving, [MEDICATION NAME] 500 mg tid (3 times a day) on 05/10/12. The nursing notes document loose, thin, liquid stools on 05/10/12, 05/11/12, 05/12/12, 05/13/ 12 and 05/14/12. treatment for [REDACTED]. Review of the 04/26/12 nutritional assessment, completed by the dietitian, found the resident required a daily fluid intake of 2550 cc. Review of the resident's documented intake of fluids, beginning with his treatment for [REDACTED]. -- 05/10/12 - 240 cc, -- 05/11/12 - 360 cc, -- 05/12/12 - 180 cc, -- 05/13/12 - no intake On 05/14/12, the resident was visited by the nurse practitioner who documented the resident to be lethargic and hypotensive. The nurse practitioner ordered 2000 cc of normal saline to be administered intravenously (IV). The order written at 10:20 a.m. on 05/14/12 specified a bolus of 1000 cc of normal saline for the first liter then 85 cc/hr for the second liter of fluids. Review of the nursing notes found IV access was obtained at 12:23… | 2015-08-01 |
| 9916 | 9916 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-06-08 | 514 | D | 1 | 0 | D9VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the medical record for one (1) of six (6) sampled residents was accurately documented. Resident #202 experienced multiple loose watery stools associated with a [MEDICAL CONDITIONS] infection. The facility failed to record the number of loose stools experienced by the resident. Resident identifier: #202. Facility census: 123. Findings include: a) Resident #202 Review of the medical record found Resident #202 was diagnosed with [REDACTED]. The nursing notes documented loose, thin, liquid stools on 05/10/12, 05/11/12, 05/12/12, 05/13/ 12 and 05/14/12. The documentation did not include an accurate accounting of the number of loose watery stools experienced by the resident. An interview with the director of nursing (DON), Employee #121 on 05/07/12 at 2:00 p.m. confirmed that nursing staff members did not accurately document the number of loose watery stools the resident experienced on the above dates. . | 2015-08-01 |
| 9917 | 9917 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-08-23 | 225 | D | 1 | 0 | T1D111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of a closed record, a review of the facility's Abuse Prohibition policy, and staff interview, the facility failed to investigate an injury of unknown origin and did not report allegations of abuse to the State agencies as required. This was true for one (1) of nine (9) sample residents. Resident identifier: #121. Facility Census: 120. Findings include: a) Resident #121 During a review of the medical record for Resident #121, it was noted that a hematoma had been found on the back of this resident's head on 08/07/12. The injury was of unknown origin. This area was significant enough that she was sent to the hospital on [DATE] for a computerized axial tomography (CAT) scan. The hospital physician described this injury as bruising and tenderness on the back of her head that went down towards her neck. It was further identified, on 08/07/12, that an Adult Protective Service Worker (APS) had come to the facility. The APS worker identified that an anonymous caller had reported the resident had been molested twice by Resident #73. According to the facility, this was the first time they had heard this allegation. The abuse and neglect files were reviewed and it was identified that this had not been reported to the State agencies. During an interview with the administrator, on 08/22/12 at 10:00 a.m., he stated that this had not been reported because there was nothing to report because it did not happen. He was questioned about why it was not reported when he was made aware of the allegation by APS. He indicated APS told him he did not have to report the allegation. A review of the facility's policy, entitled 1.0-WV Abuse Prohibition last revised 12/01/11, found included in section six (6) "Upon receiving information concerning a report of suspected or alleged abuse the Administrator or designee will: . . . .", then it stated report as follows and the directions for reporting were given. According to the review of this issue, it had b… | 2015-08-01 |
| 9918 | 9918 | ST. MARY'S HOSPITAL | 515113 | 2900 FIRST STREET | HUNTINGTON | WV | 25702 | 2012-05-08 | 225 | D | 1 | 0 | 565D11 | . Based on review of the facility's complaint log, review of policies and procedures, and staff interview, the facility failed to immediately report and failed to investigate all allegations of abuse and neglect. One (1) of two (2) complaints in the past three (3) months was not reported in accordance with State law or facility policy. In addition, this allegation regarding care, treatment, and potential neglect was not thoroughly investigated. This was true for one (1) of four (4) sampled residents. Resident identifier: #14. Facility census: 13. Findings include: a) Resident #14 Review of the facility's complaint log revealed two (2) complaints made to the facility in the last three (3) months. One of these complaints was reported and investigated. The clinical manager for the skilled unit, Employee #24, was responsible for addressing the complaint regarding Resident #14. The complaint alleged staff members did not treat residents with dignity and respect, staff members did not ensure resident rights, therapy was not provided as ordered by the physician, staff members were not implementing appropriate infection control practices, and staff members did not intervene in a timely manner when a resident became dehydrated. This complaint was written in a letter to the facility by a family member after the resident was discharged home. Review of the documentation completed by Employee #24 revealed these allegations were not thoroughly investigated. The investigation consisted only of written responses by Employee #24. The written responses to the allegations merely stated she was not aware of the issues when the resident was at the facility. Employee #24 also noted she was on the floor a lot during that time and did not hear those things. Additionally, she noted she was unaware of to whom the family had spoken. The statements written by Employee #24 contained no evidence of any attempts to identify witnesses, interview staff, or to engage in any type of investigation to determine whether or not the allegations were va… | 2015-08-01 |
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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 );