cms_WV
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39 rows where "inspection_date" is on date 2009-10-08
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Suggested facets: facility_name, facility_id, address, city, zip, deficiency_tag, scope_severity, eventid, filedate, filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10156 | 10156 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2009-10-08 | 312 | D | 0 | 1 | SM0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure two (2) female residents with long facial hair received assistance with removal of the hair. Resident identifiers: #41 and #55. Facility census: 66. Findings include: a) Resident #41 On 10/08/09 at approximately 9:30 a.m., observation of Resident #41 revealed this female had long facial hair. The resident said she had tweezers in her room and could remove them herself. An interview with Employee #47 (a licensed practical nurse - LPN) revealed this nurse had attempted to remove the resident's facial hair by shaving it off. According to the LPN, the resident refused this method of hair removal, because she thought it would make her facial hair grow back thicker. The LPN commented that this resident had a health care surrogate and, perhaps, this person would assist the resident in removing her facial hair. The nurse had a pair of scissors on her cart with [MEDICATION NAME] blades. It was suggested by the surveyor that, perhaps, the resident would allow her to use the scissors on the facial hair. At approximately 10:00 a.m., the LPN indicated the resident had allowed her to remove the facial hair using the scissors. The LPN and administrator both indicated staff had attempted several times to remove the hair in the past. b) Resident #55 Resident #55, a female resident, was also observed to have long facial hair throughout the survey. The facial hair was not removed during the four (4) days of observation. The resident would not be able to remove her facial hair independently. c) Neither resident's care plan contained information regarding their refusals to allow staff to remove their facial hair. The administrator indicated the residents would not allow the staff to groom them. However, this was not addressed in the care plans. The administrator agreed this issue should be included in the care plan. (See citation at F279.) . | 2015-06-01 |
| 10157 | 10157 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2009-10-08 | 279 | B | 0 | 1 | SM0211 | Based on record review and staff interview, the facility failed to develop care plans for two (2) female residents to address refusal of staff assistance with grooming. Resident identifiers: #41 and #55. Facility census: 66. Findings include: a) Residents #41 and #55 On 10/08/09 at approximately 9:30 a.m., two (2) female residents (#41 and #55) were observed to have long facial hair. When the administrator was questioned about the residents, he indicated these two (2) residents would not allow staff to trim their facial hair. Record review revealed these two residents' current care plans did not reflect their refusal of this care. The administrator agreed this needed to have been included in their care plans. . | 2015-06-01 |
| 10158 | 10158 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2009-10-08 | 309 | D | 0 | 1 | SM0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and facility staff interview, the facility failed to assure one (1) of thirteen (13) sampled residents and one (1) randomly observed resident received care and services in accordance with physician orders [REDACTED]. The bowel protocol was not followed when Resident #41 experienced constipation, and the nurse administered medications to Resident #18 on days when they were ordered to be held due to [MEDICAL TREATMENT] treatments. Resident identifiers: #41 and #18. Facility census: 66. Findings include: a) Resident #41 A 10/08/09 review of the medical record fount the current care plan, with a target date of 12/01/09, identified Resident #41 was at risk for complications from constipation. One (1) of the interventions to prevent this occurrence was: "Provide bowel regimen, utilize pharmacologic agents as appropriate...". Review of the bowel regimen standing orders for Resident #41 found the following: 1) If no bowel movement in three days, give milk of magnesia 30 cc PO (by mouth) X 1. 2) If no bowel movement on day four, give [MEDICATION NAME] suppository PR (per rectum) X 1. 3) If no bowel movement on day five, give Fleets enema. 4) If no results from Fleets enema, call physician for further orders. Review of the September 2009 bowel movement record found no recorded bowel movements from 09/01/09 through 09/11/09, a period of eleven (11) days. Review of the Medication Administration Record [REDACTED]. Further review noted no recorded bowel movements from 09/13/09 through 09/22/09, a time period of ten (10) days. Review of the medical record noted that nursing staff members administered milk of magnesia 30 cc on 09/16/09. The medical record found no evidence that the bowel regimen was followed by administering a [MEDICATION NAME] suppository with no bowel movement on Day 4, nor was the Fleets enema administered on Day 5 when the bowel movement record continued to record no bowel movements. The facility failed to … | 2015-06-01 |
| 10159 | 10159 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2009-10-08 | 441 | F | 0 | 1 | SM0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, review of the infection control records, facility staff interview, and facility policy review, the facility failed to establish and maintain an infection control program to prevent the potential development and transmission of disease and infection. The facility did not assure the direct care staff was properly educated concerning infection control protocols related to the use of protective equipment and handwashing. The facility did not assure environmental surfaces were properly sanitized in isolation rooms, did not assure residents with infectious diseases were appropriately cohorted, and failed to investigate and track infections present in the facility. These deficient practices had the potential to affect all sixty-six (65) residents currently residing in the facility. Facility census: 66. Findings include: a) During the initial tour of the facility on 10/05/09 at 2:10 p.m., a direct care staff member (Employee #35) was observed to enter the room of Residents #29 and #54 with cups of pudding and two (2) unwrapped plastic spoons. Observation found a sign posted on the door with instructions to report to the nursing station prior to entering the room. The employee was observed to touch the bedside table while serving pudding to Resident #29. She did not wash her hands prior to exiting the room with the second unwrapped spoon and cup of pudding. She, then, entered Resident #27's room and began feeding this resident a cup of pudding. This practice was reported to unit manager (Employee #66). She was asked why the sign was posted on the door to the room shared by Residents #29 and #54. Employee #66 stated that was for infection. When asked what infection and who had an infection, the employee stated she did not know and would have to look at the board. She directed this surveyor to a room behind the nursing station, which contained a large dry-erase board with each room and all residents listed. She referenced th… | 2015-06-01 |
| 10160 | 10160 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2009-10-08 | 502 | D | 0 | 1 | SM0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure two (2) of thirteen (13) sampled residents received ordered laboratory services to meet the needs of Residents #23 and #16. Facility census: 66. Findings include: a) Resident #23 Review of the medical record found Resident #23's treating physician ordered intravenous [MEDICATION NAME] 1 Gm every twenty-four (24) hours for a perineal abscess with [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The physician also ordered a [MEDICATION NAME] peak and trough laboratory test every three (3) days. Review of the medical record found no evidence that the ordered testing was provided. An interview with the registered nurse unit manager (Employee #66), on 10/08/09 at 5:50 p.m., confirmed the laboratory test was not obtained on 09/20/09 or on 09/23/09. b) Resident #16 Review of the medical record found a nursing note, dated 08/10/09 at 9:00 p.m., which documented that the resident had several episodes of loose, foul smelling bowel movements. The note stated the physician was notified and ordered a [MEDICAL CONDITIONS] toxin screen. The medical record contained no laboratory results until 08/19/09. Review of the document found that the specimen was collected on 08/18/09. The laboratory test was positive for [MEDICAL CONDITION]. The physician ordered [MEDICATION NAME] 250 mg four-times-a-day for ten (10) days to treat the infection. Review of the bowel movement record for the nine (9) days the facility did not obtain the ordered laboratory test found the resident continued to have multiple loose stools on 09/14/09, 09/17/09, 09/18/09, and 09/19/09. | 2015-06-01 |
| 10178 | 10178 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2009-10-08 | 246 | E | 0 | 1 | XHIH11 | Based on confidential resident interviews, review of facility's complaint log, and review of the resident council meeting minutes, the facility failed to ensure staff responded timely to requests for assistance. Staff was answering call lights when residents activated them for assistance, by turning the light off with a promise to return and not returning. This practice had the potential to more than an isolated number of residents. Resident identifiers: Withheld due to request for anonymity. Facility census: 59. Findings include: a) During the initial tour of the facility on 10/05/08 beginning at 11:30 a.m., a confidential interview with a dependent resident disclosed that his / her only complaint was when he / she turned on the call light for assistance, staff would frequently enter the room, turn off the light with a promise to return, and either not return or not return in a timely fashion. Review of the facility's log of complaints received from residents / families in the last year revealed a compliant submitted by the family of a previous resident, which alleged that, on different occasions, the resident would ask to go to the bathroom and the family would have to take him themselves, because the aide said she would "be right back, and never returned." The resident council meeting minutes for the previous three (3) months were reviewed during the course of the survey. The minutes from the September 2009 meeting stated the nurse aides were coming in and turning off the residents' call lights when they called for assistance and were not returning to help them. During a confidential group meeting on 10/06/09 at 10:30 a.m., three (3) residents in attendance reported the same complaint, that staff would come turn off their call lights and not return to assist them. . | 2015-06-01 |
| 10179 | 10179 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2009-10-08 | 329 | D | 0 | 1 | XHIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure the drug regimens, of three (3) of thirteen (13) sampled residents, were free from unnecessary drugs. Resident #27 received treatment for [REDACTED]. Resident #33 was receiving the antipsychotic drug [MEDICATION NAME] for behaviors since December 2007, in the presence of adverse consequences which indicated the dose should be reduced or discontinued. Resident #42 was receiving the antipsychotic drug [MEDICATION NAME] with no documented indication for its use. Resident identifiers: #27, #33, and #42. Facility census: 59. Findings include: a) Resident #27 Medical record review, on 10/05/09, disclosed this resident's medical [DIAGNOSES REDACTED]. Review of a quarterly minimum data set (MDS), dated [DATE], found the assessor recorded, in Section H2, the resident had diarrhea during the assessment reference period. A nursing note, dated 07/03/09, documented the resident's stool was light brownish, had some mucous in it, and was foul smelling. The note also indicated the physician, when notified, ordered a stool specimen which had been sent to the lab and [MEDICAL CONDITION] precautions were being taken. A nursing note, dated 07/04/09, indicated the physician's standing orders for [MEDICAL CONDITION] had also been started, which consisted of: Acidophilus 1 tab po (by mouth) BID (two times a day) for ten (10) days; Questran, one (1) pack in 8 oz of liquid every day for ten (10) days; [MEDICATION NAME] 500 mg 1 tab four (4) times a day for ten (10) days; Naturalogics two (2) capsules po BID while on [MEDICATION NAME]; send stool specimen for [MEDICAL CONDITION] toxin; and put resident on the acute list for the physician's assistant and call to notify her. A subsequent entry in the nursing notes, dated 07/04/09, found the lab results had been returned to the facility and the stool specimen was negative for [MEDICAL CONDITION]. This resident, whose normal bo… | 2015-06-01 |
| 10180 | 10180 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2009-10-08 | 387 | E | 0 | 1 | XHIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's admission packet, and staff interview, the facility failed to assure two (2) of thirteen (13) sampled residents were seen by their physician each month for the first three (3) months following admission and every sixty (60) days thereafter. The facility failed, as well, to assure the resident's chosen physician visited every sixty (60) days for three (3) additional sampled residents. Resident identifiers: #19, #39, #32, #42, and #15. Facility census: 59. Findings include: a) Resident #19 The medical record of Resident #19, when reviewed on 10/06/09, disclosed the resident was admitted to the facility on [DATE] following hospitalization . The resident was seen by his attending physician at the facility on 07/29/09. The resident was then seen by a physician's assistant (PA) on 08/04/09. A PA student saw the resident on 08/13/09, along with his attending physician. A visit on 09/01/09 was completed by a PA, as well as an additional visit on 09/03/09. The resident's attending physician had co-signed all entries by the others. However, the visits completed by these physician extenders did not meet the regulation, which states a physician must see the resident every thirty (30) days for the first ninety (90) days. The facility's director of nurses (DON), when interviewed related to this discovery on 10/07/09 at 3:30 p.m., stated the physician was present when a visit is done by a PA student; however, all other co-signing was done at a later date. b) Resident #39 The medical record of Resident #39, when reviewed on 10/07/09, disclosed the resident had resided at the facility since 10/19/2001. Review of recent physician visits disclosed the resident's chosen physician had visited her on 12/04/08. A PA had visited her on 01/14/09. A different physician had made a visit on 01/31/09, with subsequent visits by a PA on 02/03/09, a PA on 03/31/09, a PA on 05/05/09, and a PA on 06/09/09. The resident's chosen… | 2015-06-01 |
| 10181 | 10181 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2009-10-08 | 281 | F | 0 | 1 | XHIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of "Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses" published by the West Virginia Board of Examiners for Registered Professional Nurses and The West Virginia State Board of Examiners for Licensed Practical Nurses (dated 06/17/09), and staff interview, the facility failed to assure services provided to the residents met professional standards of quality. The facility allowed a licensed practical nurse (LPN) to act outside her scope of practice, by allowing her to complete in-depth resident assessments and make decisions related to the development of residents' care plans. This practice requires the evaluation of assessment data, which falls outside the scope of practice for an LPN. The facility also created the potential for all nurses (LPNs and registered professional nurses (RNs)) to act outside their scopes of practice, by implementing standing orders that required them to diagnose an infection and implement treatment based on this diagnosis. These practices had the potential to affect all residents of the facility. Facility census: 59. Findings include: a) During the course of the survey event, record review revealed a licensed practical nurse (LPN) was consistently completing and summarizing the individual in-depth resident assessment protocols for each resident and making the decision to proceed with care planning based on her summaries. Review of "Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses" published by the West Virginia Board of Examiners for Register Professional Nurses and The West Virginia State Board of Examiners for Licensed Practical Nurses (dated 06/17/09), revealed following: On page 6 under the heading "Review (sic) Existing Laws, Policies, and Standards of Nursing Practice": "… | 2015-06-01 |
| 10182 | 10182 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2009-10-08 | 152 | D | 0 | 1 | XHIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure determinations of incapacity were documented in accordance with State law for two (2) of thirteen (13) sampled residents. One (1) resident's determination of incapacity did not indicate the expected duration of incapacity, nor was there evidence the physician informed this alert resident that a surrogate decision-maker would be acting on her behalf. Another resident's determination of incapacity also did not note the expected duration of incapacity. Resident identifiers: Resident identifiers: #18 and #36. Facility census: 59. Findings include: a) Resident #18 The medical record of Resident #18, when reviewed on 10/05/09, disclosed the resident's physician had, on 02/05/09, determined she lacked the capacity to understand and make her own informed medical decisions. The resident had been admitted to the facility on [DATE] and had posessed capacity until this time. The physician's documentation did not indicate this alert resident had been informed that her medical power of attorney representative (MPOA) would be making medical decisions of her behalf, as required by State law. The documentation also did not include the length of time the physician expected the resident to lack this capacity. b) Resident #36 The medical record of Resident #36, when reviewed on 10/05/09, disclosed the resident's physician had determined she lacked the capacity to understand and make her own informed medical decisions. The physician's documentation did not indicate this alert resident had been informed that her MPOA would be making medical decisions of her behalf, as required by State law. In an interview on 10/07/09 at 3:30 p.m., the director of nursing (Employee #69) agreed the was no evidence to reflect physician had informed the resident that her MPOA would be making her medical decisions, as required by State law. c) According to W.V.C. 16-30-7. Determination of incapacity.: "(a) For t… | 2015-06-01 |
| 10183 | 10183 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2009-10-08 | 279 | D | 0 | 1 | XHIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for three (3) of thirteen (13) residents that described the services to be furnished and how the services would be provided. Resident # 30's pain control program was not described specifically in the care plan. Residents #42 and #19 were receiving services at a wound care clinic that was not described in their care plans. Resident identifiers: #30, #42, and #19. Facility census: 59. Findings include: a) Resident #30 Medical record review, on 10/06/09, disclosed this resident sustained [REDACTED]. Among the other numerous medical [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. There were also orders for [MEDICATION NAME] 5/325 every six (6) hours as needed (PRN) for moderate to severe pain and [MEDICATION NAME] 50 mg every four (4) hours PRN for moderate pain. Interview with the medication nurse, on 10/06/09 at 3:00 p.m., revealed the resident's pain was assessed, and he was initially given [MEDICATION NAME] alternated with Tylenol; the [MEDICATION NAME] was not given unless the resident's pain was not relieved. The nurse related the resident's parents did not want the [MEDICATION NAME] given unless absolutely necessary, due to a decrease in respirations and an increase in lethargy. Review of the resident's comprehensive care plan, dated 11/25/09, found the resident's pain control plan did not contain the information described by the medication nurse. During an interview on 10/07/09 at 3:30 p.m., the director of nursing (DON - Employee #69) agreed this information should have been included in the care plan to ensure consistent care was provided by all staff. b) Resident #42 The medical record of Resident #42, when reviewed on 10/07/09, disclosed the resident was admitted to the facility on [DATE]. The record contained recent documents describing care and providing orders for wound care from an outside Wound Clinic. When i… | 2015-06-01 |
| 10347 | 10347 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 164 | D | 0 | 1 | 5TIO11 | Based on observation and staff interview, the facility failed to protect the privacy of one (1) of thirteen (13) sampled residents by leaving confidential resident information observable in a hallway unattended. Resident identifier: #30. Facility census: 58. Findings include: a) Resident #30 When entering the room of Resident #30 for an observation of wound care at 11:10 a.m. on 10/06/09, the surveyor observed the treatment administration record lying open on top of the treatment cart located in the hallway outside the room. The resident's name, wound status, and treatment information were accessible to anyone who stopped in the hallway. Both of the treatment nurses (Employees #74 and #34) had already entered the room. The door was left open throughout the treatment, and the record was still open when the room was exited approximately fifteen (15) minutes later. During an interview with the assistant director of nursing (Employee #74) and the wound care nurse (Employee #62) at 10:30 a.m. on 10/07/09, they were informed of the observation. . | 2015-05-01 |
| 10348 | 10348 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 241 | D | 0 | 1 | 5TIO11 | Based on observation, record review, and staff interview, the facility failed to provide care with dignity by discussing care issues in the presence of an alert resident and in an area that did not assure auditory privacy for one (1) of thirteen (13) sampled residents. Resident identifier: #30. Facility census: 58. Findings include: a) Resident #30 During the provision of wound care by two (2) nurses (Employees #34 and #74) for Resident #30 in the resident's room at 11:10 a.m. on 10/06/09, Employee #74 stood by the resident's head at the top of the bed during the procedure. The resident was on the window bed farthest from the door, and the privacy curtain was pulled between the beds, but the door was not closed. The room was located on the main hallway from the front entrance, and several staff members and others were seen passing in the hall. While the resident could not be seen from the open door, the overbed table and its supplies were visible, making it obvious that wound care was being done. This surveyor stood against the wall across from the foot of the bed. At the start of the wound care, the resident was turned to face the inside of the room. At that time she said, on three (3) separate occasions and in a voice audible to this surveyor, that she needed to use the bathroom. Neither nurse acknowledged this request the first two (2) times; on her third try, when she said she had to "go bad" and apologized by saying, "I'm sorry", Employee #74 told her, "It's OK. This won't take long." At one point, Employee #74 asked the resident if she was having pain, and the resident replied that she was, but the nurse said nothing, and they continued with the procedure. During the procedure, Employee #34 related to this surveyor information which included the status of the wounds present, the care being given, and traits that the resident had that impeded the healing process. She stated the resident was refusing to eat, would not let them turn her off of the affected side often enough, and that she would not heal as long… | 2015-05-01 |
| 10349 | 10349 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 272 | E | 0 | 1 | 5TIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the accuracy of the minimum data set (MDS) assessments for four (4) of the thirteen (13) sampled residents. Resident identifiers: #49, #21, #42, and #10. Facility census: 58. Findings include: a) Resident #49 Medical record review revealed Resident #49 was an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her admission MDS revealed, in Section M.1., the presence of two (2) Stage I, one (1) Stage II, and one (1) Stage IV pressure ulcers. A review of the significant change in status MDS, dated [DATE], indicated in Section M.1. the presence of one (1) Stage II and one (1) Stage IV pressure ulcers, but there was no entry in Section M.3. to indicated there were any resolved ulcers. This made the status of the resident unclear. During an interview with the MDS nurse (Employee #47) at 3:45 p.m. on 10/10/07/09, she acknowledged there should have been an entry in Section M.3., as she was sure two (2) of the ulcers had healed. b) Resident #21 Medical record review revealed Resident #21 had been receiving a diuretic ([MEDICATION NAME]) daily since at least November 2008, but the significant change in status MDS, dated [DATE], failed to indicate this in Section O.4. The MDS nurse, when questioned at 3:45 p.m. on 10/07/09, stated this was an oversight. c) Resident #42 Medical record review revealed Resident #42 was an [AGE] year old female with [DIAGNOSES REDACTED]. The resident's care plan contained a problem initiated on 05/10/09, stating: "Resident at times sits up all night not allowing staff to put her to bed." She was ordered [MEDICATION NAME] 25 mg each night for sleep, and this medication was increased to 50 mg on 08/15/09, after a psychiatric consult on 08/13/09, when the physician noted she was "somnolent" during the examination. A review of the annual MDS, dated [DATE], and the quarterly MDS, dated [DATE], found not mention, in… | 2015-05-01 |
| 10350 | 10350 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 274 | D | 0 | 1 | 5TIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a comprehensive assessment minimum data set (MDS) for one (1) of thirteen (13) sampled residents who exhibited a significant change in health status. Resident identifier: #42. Facility census: 58. Findings include: a) Resident #42 Medical record review revealed Resident #42 was an [AGE] year old female with [DIAGNOSES REDACTED]. The facility completed an annual MDS on 05/04/09 and a quarterly MDS on 07/26/09. A comparison of these assessments revealed following changes: Section E1 (indicators of depression, anxiety, sad mood) - repetitive verbalizations and repetitive anxious complaints / concerns increased from less than six (6) times a week to daily or almost daily, and repetitive movements increased from non to less than six (6) times a week. Section E2 (mood persistence) - changed from present and easily altered to present and not easily altered. Section 4 (behavioral symptoms) - the frequency of resisting care increased from occurring one (1) to three (3) days in the last seven (7) days to occurring four (4) to six (6) days in the last seven (7) days. Section O4b - the resident was now receiving a medication for antianxiety. During an interview with the MDS nurse (Employee #47) at 3:45 p.m. on 10/07/09, she acknowledged, after reviewing the record, that the 07/26/09 MDS should have been a comprehensive significant change in status assessment instead of an abbreviated quarterly assessment. . | 2015-05-01 |
| 10351 | 10351 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 279 | E | 0 | 1 | 5TIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to initiate a care plan and/or adequately address all problems identified through the comprehensive resident assessment for nine (9) of fifteen (15) sampled residents, by either not establishing measurable goals and/or by the lack of nursing interventions designed to meet the goals. Resident identifiers: #3, #4, #13, #42, #59, #36, #24, #48, and #57. Facility census: 58. Findings include: a) Residents #3, #13, #42, #59, #36, #24, and #48 Each of these seven (7) residents was receiving one (1) or more psychoactive medications on a continuing basis including [MEDICATION NAME], [MEDICATION NAME], and/or [MEDICATION NAME]. These medications were identified in their comprehensive minimum data set (MDS) assessments, which triggered the resident assessment protocol (RAP) for [MEDICAL CONDITION] drug use. In each case, the interdisciplinary care team identified on the resident's RAP summary that the team would proceed with care planning the medication use to observe for the effectiveness of medication, potential medication side effects, and potential dosage reductions. However, none of residents' care plans contained a problem, under the column headed "Focus", for [MEDICAL CONDITION] drug use and there were no measurable goals established for this. The only entries found were the following statement under "Interventions": "Administer antipsychotic and antidepressant per MD orders. Observe for effectiveness and side effects." This intervention was usually addressing a behavioral or cognitive problem. In none of these residents' care plans were any of the side effects listed, although, in the documentation of the care plan meeting, at times, mentioned potential safety issues. During a meeting with the MDS nurse (Employee #47), the assistant director of nursing (Employee #74), and the administrator at 4:00 p.m. on 10/07/09, the MDS nurse acknowledged she did not address the use of a [MEDICA… | 2015-05-01 |
| 10352 | 10352 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 280 | D | 0 | 1 | 5TIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to review and/or revise the care plan to include changes in health care needs including a significant weight loss due to poor intake for one (1) of thirteen (13) sampled residents. Resident identifier: #21. Facility census: 58. Findings include: a) Resident #21 A review of the significant change in status minimum data set (MDS), dated [DATE], revealed Resident #21 had a weight loss of 5% or more in the last thirty (30) days or 10% or more in the last one hundred eighty (180) days (Section K3a), and that she left twenty-five percent (25%) or more of food uneaten at most meals (Section K4c). The care plan meeting notes for 08/19/09 stated: "MDS and Careplan reviewed for significant change in status on 8/12/09. Significant change due to weight loss, ..." and "Resident has exhibited a weight loss over past months. She is taking a regular no added salt diet with sugar substitute. Resident is able to feed self but needs much encouragement." These changes in the MDS triggered the resident assessment protocol (RAP) for nutritional status, which included the above assessment information, and the interdisciplinary care team indicated that care planning would be done to address this. A review of the care plan, with a print date of 08/17/09, revealed the following entry on page 6 as an addition under the problem of dehydration: "8/17/09 Res (resident) has exhibited significant weight loss over past review. At risk for additional weight loss due to poor intakes. Continue with POC (plan of care)." There was no goal associated with this entry and no nursing interventions as suggested in the care plan meeting. During an interview with the MDS nurse (Employee #47) at 3:45 p.m. on 10/07/09, she reviewed the care plan and agreed it contained no interventions, possibly due to an oversight. . | 2015-05-01 |
| 10353 | 10353 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 285 | B | 0 | 1 | 5TIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the mental health status of a new resident had been evaluated under the Pre-Admission Screening and Resident Review (PASRR) program prior to the resident being admitted into the facility for three (3) of fifteen (15) sampled residents. Resident identifiers: #60, #36, and #49. Facility census: 58. Findings include: a) Resident #60 Review of Resident #60's medical record, on 10/07/09, revealed he was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 06/19/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. b) Resident #36 Review of Resident #36's medical record, on 10/06/09, revealed she was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 07/27/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. c) Resident #49 A review of the clinical record revealed Resident #49 was admitted to the facility on [DATE]. However, the Level II determination was not made, as indicated by the dated signature in Section V of the PASRR, until 07/15/09. During an interview with the administrator and the social worker at 10:15 on 10/08/09, they acknowledged the dates noted above were correct. . | 2015-05-01 |
| 10354 | 10354 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 329 | D | 0 | 1 | 5TIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen of one (1) of thirteen (13) sampled residents was free of unnecessary drugs. There was a lack of monitoring for sleeplessness to ascertain the effectiveness of [MEDICATION NAME] in treating [MEDICAL CONDITION], and there was a lack of monitoring for the presence of adverse side effects associated with the use of the [MEDICATION NAME]. Resident identifier: #42. Facility census: 58. Findings include: a) Resident #42 Medical record review revealed Resident #42 was an [AGE] year old female with [DIAGNOSES REDACTED]. The resident's care plan contained a problem initiated on 05/10/09, stating: "Resident at times sits up all night not allowing staff to put her to bed." Her physician ordered [MEDICATION NAME] 25 mg each night to promote sleep. The dosage of this medication was increased on 08/15/09 to 50 mg after a psychiatric consult on 08/13/09, during which the physician noted, "She's still having problems with decreased sleep at night" and that she was "somnolent during the examination". Review of the resident's annual comprehensive assessment, dated 05/04/09, and the most recent abbreviated quarterly assessment, dated 07/26/09, found no entries in Section E1 to indicate the resident exhibited signs of "sleep-cycle issues". The resident assessment protocol (RAP) for [MEDICAL CONDITION] drug use stated: "Will proceed with care plan to observe effectiveness of medication, potential medication side effects and for potential dosage reductions." However, the only entry in the care plan was: "Administer antipsychotic and antidepressant per MD orders. Observe for effectiveness and side effects." A review of seventeen (17) interdisciplinary team progress notes, written between 07/27/09 and 08/10/09, only revealed one (1) entry (on 07/27/09) which addressed her problem of not sleeping, stating, "Resident continues to sit up at night at times, refusing to go to… | 2015-05-01 |
| 10355 | 10355 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 386 | D | 0 | 1 | 5TIO11 | Based on record review and staff interview, the facility failed to assure a physician signed and dates all orders received for the care of one (1) of thirteen (13) sampled residents in a timely manner. Resident identifier: #49. Facility census: 58. Findings include: a) Resident #49 A review of the clinical record for Resident #49 revealed the attending physician's last required visit was on 09/16/09, with progress notes entered by him into the record and signed and dated. But there were five (5) verbally received treatment orders from August and eight (8) from September (prior to his visit date) that were not signed or dated to reflect his review. The monthly recapitulation of physician orders for September was on the record on 08/31/09, and these were also not signed or dated. During an interview with the administrator at 10:20 a.m. on 10/08/09, when informed of the physician's failure to sign the orders, she stated all orders should have been signed and she would review the chart. At the time of exit, no additional information had been received regarding this concern. | 2015-05-01 |
| 10527 | 10527 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 463 | D | 0 | 1 | 4DOJ11 | Based on performance testing and staff interview, the facility failed to ensure the nurse call system was fully functional for all residents. The call bells for room #108 did not function when tested by the surveyor. This was evident for one (1) of fourteen (14) sampled residents whose call bells were evaluated for functioning. Facility census: 112. Findings include: a) The surveyor evaluated the operation of nurse call bells on the afternoon of 10/06/09 for the residents in the Phase I sample. This performance testing discovered the call bells did not activate for the resident in room #108. The surveyor requested the nursing assistant (Employee #62) who was in the hall way to check the call light with her. The light was found to not operate for the resident in either bed in the room. . | 2015-02-01 |
| 10528 | 10528 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 252 | E | 0 | 1 | 4DOJ11 | Based on staff interview and observation, the facility failed to provide a safe, clean, comfortable environment for its residents. The walls around the nursing station on the West wing were banged and scratched; bangs and scratches were noted n the wall of the shower room near the tub, and the wall in the hallway outside of the shower room was missing wallpaper. These conditions did not prevented the surfaces from being easily cleaned. This was evident for one (1) of two (2) nursing units. Facility census: 112. Findings include: a) Observations, on the afternoon of 10/06/09, found the walls around the nursing station serving the West wing of the facility were banged and scratched. The wall of the shower room serving this unit was banged and scratched above the baseboard. Additionally, a section of wall paper was missing below the hand railing in the outside hall way of the 300 wing. These conditions do not allow the areas to be easily cleaned by staff. The maintenance supervisor verified these observations later in the afternoon of 10/06/09. . | 2015-02-01 |
| 10529 | 10529 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 364 | D | 0 | 1 | 4DOJ11 | Based on random observation on 10/05/09 and staff interview, the facility failed to ensure meals were pleasing in appearance. This was evident for one (1) resident of random opportunity. Resident identifier: #104. Facility census: 112. Findings include: a) Resident #104 The evening meal was observed on the West wing on 10/05/09, in the unit's small dining room. Resident #104 was noted to receive a stuffed pepper which had juice that was running all over the plate. A side dish of greens was found to be setting in the juice. This did not make for an appealing appearance on the tray. This observation was discussed with the dietary manager at 11:10 a.m. on 10/08/09. . | 2015-02-01 |
| 10530 | 10530 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 502 | D | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain laboratory tests as ordered by the physician. These laboratory tests were ordered to be done every month and, as of 10/06/09, they had not been done since 08/21/09. Ordered test were not completed for one (1) of twenty (20) sampled residents. Resident identifier: #51. Facility census: 112 Findings include: a) Resident #51 Review of the medical record revealed this resident had a physician's orders [REDACTED]. Further review of the medical record revealed this resident's last CBC and BMP had been done on 08/21/09. There was no evidence to indicate these tests were performed in September 2009. The registered nurse (Employee #16), when questioned about the laboratory data on 10/06/2009 at 2:00 p.m., was unable to locate the data and verified that, after researching this, the resident had not had the laboratory tests completed as ordered. The facility performed these test immediately after it was identified that they were not completed. | 2015-02-01 |
| 10531 | 10531 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 318 | D | 0 | 1 | 4DOJ11 | Based on medical record review, observation, and staff interview, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (1) of twenty (20) sampled residents. Resident #12 was unable to fully extend her legs and had limited range of motion. Review of assessments, nursing notes, and care plan failed to find evidence the resident was assessed, care planned, or provided services to prevent further decrease in range of motion. Facility census: 112. Findings include: a) Resident #12 Observation of this resident on 10/05/09, 10/07/09, and 10/08/09, found the resident's legs would not fully extend. The resident was observed on 10/06/09 while a nursing assistant (NA - Employee #61) attempted to reposition the resident in the bed. The resident was observed while seated in a geri-chair on 10/06/09 and 10/07/09, and the resident's legs did not fully extend on any of the observations. During observations on the mid-afternoon of 10/07/09, with the director of nursing (DON) and an occupational therapist, two (2) NAs (Employees #56 and #68) sat the resident on the side of the bed, and the occupational therapist handed the NAs a gait belt. The resident's bed was low and unable to be raised in order for the NAs to help the resident sit in an upright position. The resident was stooped over with her head leaning forward towards her knees. When questioned if the gait belt was always used to transfer the resident, Employee #56 said, "Always, sometimes." The resident was able to put her feet down but was not able to fully extend her legs in order to stand up, and she was not able to fully bear any weight. The DON had to assist the NAs by bringing the geri chair behind the resident and holding it in place while they lifted the resident into the geri-chair. With the occupational therapist present, Resident #12 then pulled her legs up towards her chest and assumed a drawn up position, allowing … | 2015-02-01 |
| 10532 | 10532 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 323 | E | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of the facility's smoking policy, and resident and staff interviews, the facility failed to ensure three (3) of ten (10) residents who smoked, and who were assessed as requiring supervision for safe smoking, did not have access to lighters while unsupervised. Additionally, the facility failed to ensure one (1) of twenty (20) sampled residents, who was identified as being at risk for falls, had mats beside her bed as ordered. Resident identifiers: #12, #45, #82, and #103. Facility census: 112. Findings include: a) Residents #103, #45, and #82 1. Resident #103 Observation of Resident #103 on 10/6/09 at 4:00 p.m., found the resident sitting on the side of his bed while rolling his own cigarettes. At 8:50 a.m., on 10/07/09, the social worker was interviewed about residents who were allowed to smoke at the facility. She indicated that the residents who smoked were allowed to keep their own cigarettes, but could not have any lighters or matches, and these were given to the residents during scheduled smoking times. She indicated that the smoking schedule was a recent change at the facility in order to ensure that residents who smoked were safe and supervised. At 9:00 a.m. the social worker was accompanied by the surveyor the Resident #103 was observed in the hallway. He indicated that he was on his way to smoke outside. Whenever questioned as to if he had a lighter, he said, "Yes." The social worker then asked the resident to give her the lighter, and the resident complied. Whenever asked who gave him the lighter, he indicated it was as staff member from the day before, but could not name the person. Review of the Safe Smoking assessment dated [DATE] and reviewed on 06/17/09, found the resident required supervision to smoke. A review of the resident's care plan dated 09/16/09 and did not include a care plan to ensure safe smoking for the resident. 2. Resident #45 During an interview on 10/07/09 at … | 2015-02-01 |
| 10533 | 10533 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 441 | E | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of facility policies and procedures, the facility failed to maintain an effective infection control program. This had the potential to affect residents residing on two (2) of four (4) hallways in the facility. Resident #12 was fed from an overbed table brought into her room from another resident's room without first being cleaned. Employee #61 was observed wiping off the sink with paper towels, recontaminating his hands after washing them. Employee #32 was observed using a stethoscope for Resident #62 who was in contact isolation for VRE; she then put the stethoscope around her neck and took the stethoscope out of the room without cleaning it first. Employee #36 was observed contaminating her gloves during medication administration and then touching items (including drinking cups) on her medication cart. Facility census: 112. Findings include: a) Resident #12 During the evening meal on 10/05/09, observation found a nursing assistant (NA - Employee #61) pushed an overbed table from the room adjacent to Resident #12's room into the resident's room without cleansing it first. The NA then put the resident's dinner tray on the table and proceeded to feed the resident. b) Employee #61 Employee #61 was observed during the evening meal on 10/05/09. After washing his hands, the NA took paper towels from the dispenser and wiped off water that accumulated around the sink basin on the counter, recontaminating his hands. This occurred two (2) times during this observation. c) Resident #62 and Employee #32 Observation, on 10/06/09 in the mid-morning, found a licensed practical nurse (LPN - Employee #32) using a stethoscope to check Resident #62's [DEVICE] placement during medication administration. Resident #62 was in contact isolation for [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE ). The nurse took the stethoscope with her when she exited the room and put it around her neck without cleansing the … | 2015-02-01 |
| 10534 | 10534 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 492 | E | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure services were provided in accordance with State laws. Residents with "Physician order [REDACTED]. Additionally, a POST form for one (1) resident was marked for the resident not to have a feeding tube. The form was not revised after a feeding tube was inserted during a hospitalization , in keeping with [DATE] of the West Virginia Code. Resident identifiers: #24, #25, #99, #90, #113, #83, and #103. Facility census: 112. Findings include: a) Resident #24 1. Review of the resident's medical record found a POST form signed by the resident's health care surrogate (HCS) on [DATE]. The physician also signed the form on [DATE]. The form indicated the resident was NOT to have a feeding tube. However, the resident had a feeding tube inserted while in the hospital [DATE] to [DATE]. In Section G of the form, it was noted the form had been reviewed on [DATE]. An "X" had been placed in the box by "No Change" and the physician had signed the form. There was no indication the HCS had been involved in reviewing the form and it determined whether she wanted the feeding tube to be continued, nor had the form been voided and a new one completed to allow for the feeding tube. West Virginia State Code, [DATE], includes, "After admission, the physician orders [REDACTED]. "(1) The physician orders [REDACTED]. "(2) The physician orders [REDACTED]. "(3) The physician orders [REDACTED]." 2. Additionally, the form had been marked for the resident to be "Comfort Measures". There was no evidence the HCS had been provided information stating the resident had the option of receiving hospice palliative care. West Virginia State Code, ,[DATE]C-20 includes, "Hospice palliative care required to be offered. "(a) When the health status of a nursing home facility resident declines to the state of terminal illness or when the resident receives a physician's orders [REDACTED]. If a nursing home resi… | 2015-02-01 |
| 10535 | 10535 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 225 | D | 0 | 1 | 4DOJ11 | Based on medical record review and staff interview, the facility failed to adequately screen applicants to ensure it did not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law. One (1) of five (5) new employees whose personnel files were reviewed worked in another state, and the facility did not check that state for possible criminal convictions that would indicate the applicant was unfit for service in a nursing facility. Employee identifier: #18. Facility census: 112. Findings include: a) Employee #18 Review of the employment application for Employee #18 found this individual had worked in Texas in 2009. Review of the criminal background check, which included several other states, found it did not include Texas. This finding was reviewed with the certified nursing assistant supervisor (Employee #11) at 11:00 a.m. on 10/06/09. Employee #11 was unable to produce evidence to reflect the facility made reasonable efforts to screen Employee #18 for past criminal convictions in other states in which the individual had previous employment prior to hire. . | 2015-02-01 |
| 10536 | 10536 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 279 | E | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policies and procedures, and staff interviews, the facility failed to develop care plans for three (3) of ten (10) residents who smoked at the facility, seven (7) of twenty-three (23) sampled residents who had a physician's orders [REDACTED]. Residents #45, #83, and #103 smoked, and care plans were not developed to ensure resident safety. Residents #113, #83, #103, #4, #23, #99, and #25 had physician's orders [REDACTED]. Resident #99 exhibited problem behaviors, and the care plan did not include measurable goals or provide guidance to direct the care giver on redirection. Facility census: 112. Findings include: a) Residents #45, #83, and #103 (residents who smoked) 1. Residents #103 Observation of Resident #103, on 10/6/09 at 4:00 p.m., found the resident sitting on the side of his bed rolling his own cigarettes. At 8:50 a.m. on 10/07/09, the social worker, when interviewed about residents who were allowed to smoke at the facility, related the residents who smoked were allowed to keep their own cigarettes but could not have any lighters or matches; these were given to the residents during scheduled smoking times. She related the smoking schedule was a recent change at the facility in order to ensure residents who smoked were safe and supervised. At 9:00 a.m., the social worker accompanied the surveyor to see Resident #103, who was observed in the hallway. Resident #103 stated he was on his way to smoke outside. When questioned as to if he had a lighter, he said, "Yes." The social worker then asked the resident to give her the lighter, and the resident complied. When asked who gave him the lighter, he related it was a staff member from the day before, but he could not name the person. Review of the Safe Smoking Assessment, dated 03/25/09 and reviewed on 06/17/09, found Resident #103 required supervision to smoke. A review of the resident's current care plan, dated 09/16/09, found it did not include a ca… | 2015-02-01 |
| 10537 | 10537 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 281 | D | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and staff interview, the facility failed to ensure residents received medications as ordered for one (1) of forty (40) opportunities for error observed. Resident #98 received regular Aspirin 325 mg, although Aspirin 325 mg EC ([MEDICATION NAME] coated) was ordered. Resident identifier: #98. Facility census: 112. Findings include: a) Resident #98 During the medication pass on 10/06/09 at 9:05 a.m., the nurse (Employee #41) administered to Resident #98 regular Aspirin 325 mg, instead of Aspirin 325 EC as ordered by the physician. This information was reviewed with the director of nursing on 10/08/09 at 3:00 p.m., who verified the wrong medication had been given. Review of the facility's "Guidelines for Administering Medications", in Section E "General rules for giving Medications" found, under Item #4, "Check the MAR (medication administration record) with the label on the medication three times, reading the name on the medication, the route of the administration, and the strength dose..." . | 2015-02-01 |
| 10538 | 10538 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 272 | D | 0 | 1 | 4DOJ11 | Based on review of medical records and staff interviews, the facility failed to ensure the minimum data set (MDS) assessment for one (1) of twenty (20) current residents on the sample was accurately coded with regard to her skin condition. The assessment was coded to indicate the resident had a pressure ulcer, although the physician had documented the area was a diabetic ulcer. Resident identifier: #90. Facility census: 112. Findings include: a) Resident #90 The "Resident Level Quality Measure / Indicator Report: Chronic Care Sample" (run date 09/30/09) indicated this resident had a pressure ulcer. On 10/05/09 at approximately 4:00 p.m., the treatment nurse (Employee #26), when asked about the ulcers of three (3) residents on the unit, said all three (3) had "diabetic pressure ulcers". Subsequent review of Resident #90's medical record found the physician had diagnosed the area as a diabetic ulcer. The resident's MDS, with an assessment reference date (ARD) of 08/08/09, was coded as "2" in Section M - item 2a, to indicate the resident had a pressure ulcer. The diabetic ulcer should have been coded in M1, but not in M2. . | 2015-02-01 |
| 10539 | 10539 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 309 | E | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, and staff interviews, the facility failed to ensure each resident received the necessary care and services to promote his or her highest level of well-being and in accordance with the plan of care. Physicians' orders were not carried out for two (2) of twenty (20) sampled residents. Resident identifiers: #25 and #24. Facility census: 112. Findings include: a) Resident #25 1. This resident was admitted on [DATE]. Her admission orders [REDACTED]." Review of the resident's medical record did not find any record of intakes and outputs. The book in which current intake and output records was reviewed, but no records were found for this resident. On 10/07/09 at approximately 2:45 p.m., a registered nurse (Employee #16) was asked to find the record of the resident's intakes and outputs. She checked the resident's chart and the intake and output book, but was unable to locate any records. She said the order must have been missed. 2. On 09/16/09, telephone orders had been written for the resident, to include an order for [REDACTED]. The Accu-Checks were completed as ordered and documented on Medication Administration Record [REDACTED]. At the end of the five (5) day period, "REEVAL" had been written, but there was no evidence the data were evaluated. The Accu-Checks were documented for four (4) days at 6:00 a.m. - no insulin coverage was required. The checks for 11:00 a.m. were completed all five (5) days. For the first three (3) days, no insulin coverage was required. On the last two (2) days, two (2) units of regular insulin were given. The results for the 4:00 p.m. tests indicated insulin coverage was required on 09/16/09, 09/17/09, and 09/20/09. Eight (8) units of insulin were given on 09/17/09, and two (2) units were given the other two (2) days. The 9:00 p.m. tests indicated insulin coverage was required on 09/17/09, 09/18/09, and 09/20/09. Four (4) units were required on 09/17/09, and two … | 2015-02-01 |
| 10540 | 10540 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 310 | D | 0 | 1 | 4DOJ11 | Based on random observations, the facility failed to ensure a resident's ability to eat did not diminish. Resident #36 was not positioned to facilitate ease in feeding herself. Facility census: 112. Findings include: a) Resident #36 On 10/05/09, the resident was observed eating the evening meal in the small dining room on the West wing. She was seated in a geri-chair, and her meal tray was on an overbed table. The back of the recliner was at 45 degrees, and her food was at the height of her mouth. She could not well visualize the foods on her plate. She would extend her arm and attempt to scoop food onto the spoon, but at times she would get little or no food. Because of the height and positioning of the chair relative to the table, not only could she not see what was on the plate too well, she had to extend her arm and hand above shoulder height to obtain the foods and beverages she had been served. Observation of the resident at lunch time, on 10/06/09 and 10/07/09, found similar positioning. On 10/07/09, the resident's positioning was discussed with the dietary manager and a registered nurse (Employee #16). . | 2015-02-01 |
| 10541 | 10541 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 325 | D | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, and staff interviews, the facility failed to ensure each resident maintained acceptable parameters of nutrition. There was no evidence the facility had recognized and evaluated a resident's 15 pound weight loss. One (1) of twenty (20) current residents on the sample was affected. Resident identifier: #25. Facility census: 112. Findings include: a) Resident #25 This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her admission comprehensive minimum data set (MDS) assessment, with an assessment reference date of 09/18/09, indicated she had [MEDICAL CONDITION] present during the seven (7) day look-back period. Her weight was listed as 268 pounds. She was not coded as being on a weight loss program. A form entitled "Restorative" had an instruction for weekly weights four (4) times. The first weight was listed for 09/07/09 (actually the day before she was admitted ) at 265 pounds. On 09/11/09, she again weighed 265 pounds. On 09/16/09, her weight had dropped to 252 pounds; on 09/23/09, she weighed 254 pounds; and by 09/30/09, she weighed 250 pounds. That was 15 pounds less than her initial weigh listed on the restorative document and eighteen 18 pounds less than the weight listed on her admission assessment. Further review of her medical record, i.e., dietary progress notes, nursing notes, and physician progress notes [REDACTED]. A registered nurse (Employee #16), when interviewed at approximately 2:45 p.m. on 10/07/09, acknowledged the resident's weight loss and said she had not been made aware. During an interview with the resident at 2:15 p.m. on 10/07/09, she stated she knew she had lost weight. She recounted she had eaten at a certain fast food restaurant prior to admission and now she had a healthier diet. The resident's weight loss was further discussed with medical records staff (Employee #8) and Employee #16 during the morning hours on 10/08/09. That she h… | 2015-02-01 |
| 10542 | 10542 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 386 | D | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure the physician recorded a progress note at the time of each visit reflecting an evaluation of the resident's condition and decisions about the continued program of the resident's current regimen. An open area on the resident's right heel was noted in July 2009, but it was not reflected in the physician's progress notes. One (1) of twenty (20) current residents on the sample was affected. Resident identifier: #24. Facility census: 112. Findings include: a) Resident #24 The resident's monthly recapitulation of physician's orders for July 2009 did not include any orders for treatment to the resident's right heel. On 07/10/09, a physician's order was written for: "Cleanse (R) (right) heel /c (with) NSS (normal saline solution), dry well, pad /c Collagen & secure /c hypofix QD (every day) & PRN (as needed) d/t (due to) breakdown." This order was continued on the orders for August, September, and October 2009. On 10/06/09 at approximately 2:00 p.m., a licensed practical nurse (LPN - Employee #26) was asked what kind of area the resident had on her right heel. She said it was a diabetic ulcer. The nursing documentation in the resident's medical record referred to "Decub(itus) update" and "diabetic pressure ulcer." The physician progress notes [REDACTED]. Both progress notes, under "Extremities", noted: "No [MEDICAL CONDITION], no cyanosis, no clubbing." The ulcer was not referenced in the "Assessment" portion of the physician's note, nor was it mentioned elsewhere. A letter from the West Virginia Board of Medicine, dated 05/18/07, in response to a query by the West Virginia Health Care Association, included, "It was the determination of the members that there must be a formal [DIAGNOSES REDACTED]. This constitutes the practice of medicine. If a registered professional nurse makes the determination, it must be reviewed by a licensed physician." The LPN who provided … | 2015-02-01 |
| 10543 | 10543 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 246 | D | 0 | 1 | 4DOJ11 | Based on observations and staff comments, the facility failed to provide reasonable accommodations to meet the needs of residents. One (1) of twenty (20) sampled residents was not positioned for comfort in a geri chair. Additionally, the facility failed to adapt the physical environment to enable residents to maintain unassisted functioning, in that a large clock, located in the dining room on the West wing, did not accurately reflect the time. All residents dining in the small dining room on the unit had the potential to be affected. Facility census: 112. Findings include: a) Resident #12 Observations, throughout the day on 10/06/09 and 10/07/09, found Resident #12 seated in a geri-chair with the foot rest elevated. The resident's feet were positioned on a metal bar with extensions located in the space between the geri-chair and the foot rest. The geri chair had a fitted sheet under the resident, which was not pulled over the bottom part of the chair, nor were there any pillows in the geri chair to cushion the resident's feet from the metal bars or extensions. b) Observations on the West wing, on 10/05/09 at approximately 3:30 p.m., found the large clock in the small dining area did not accurately reflect the time. The hands of the clock displayed at several minutes after 12:00. During the evening meal at 5:40 p.m., the hands of the clock had not moved since the initial observation. Additional observations found the hands of the clock remained in the same position throughout the survey. During the exit conference on 10/08/09, the administrator commented he had noticed the clock was not working on 10/05/09. He said he had instructed a staff member to change the batteries, but apparently it had not been done. The clock provided a measure to orient / reorient residents to the time of day without staff assistance. . | 2015-02-01 |
| 10544 | 10544 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 285 | D | 0 | 1 | 4DOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure an independent mental evaluation, as required by a Level I pre-admission screening, was performed prior to admitting a resident. An applicant for admission was admitted to the facility approximately one (1) month prior to the survey, but the results of her Level II examination, to identify whether specialized rehabilitative services were required, were not available. One (1) of twenty (20) current residents on the sample was affected. Resident identifier: #25. Facility census: 112. Findings include: a) Resident #25 The pre-admission screening instrument (PAS-2000), specified by the State Medicaid agency, was signed by a nurse reviewer on 09/03/09. This was prior to the resident's admission to the nursing home. The Level I screening required a Level II examination be completed prior to the resident's admission. According to Chapter 514 - Covered Services, Limitations, and Exclusions for Nursing Facility Services: "514.9.2 PRE-ADMISSION SCREENING (LEVEL II) - If the Level I evaluation found the possible presence of MI (mental illness) and/or MR/DD (mental [MEDICAL CONDITION] / developmental disability), further evaluation of the individual must be completed to obtain a definitive [DIAGNOSES REDACTED]. ... It is the responsibility of the referring entity to arrange for an evaluation (Level II). This evaluation must be completed, including a report of the mental health status and whether specialized services are needed, within 7-9 days following the referral and prior to the individual ' s admission into a nursing facility." Review of the resident's medical record did not find the report of the Level II examination. On 10/07/09 at approximately 2:50 p.m., a registered nurse (Employee #16) was asked to locate the Level II examination results. She was unable to locate the results of the examination. The Level II report had not been provided as of exit conference m… | 2015-02-01 |
| 10545 | 10545 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2009-10-08 | 241 | D | 0 | 1 | 4DOJ11 | Based on observation, staff interview, and medical record review, the facility failed to promote care in a manner and in an environment that maintained or enhanced dignity and respect in full recognition of each resident's individuality. One (1) of twenty (20) sampled residents (Resident #12), who was dependent upon staff for all activities of daily living, was observed in a low bed that would not raise to a higher level to facilitate the provision of care in a dignified manner. Facility census: 112. Findings include: a) Resident #12 1. Observations of meal service, from 5:30 p.m. through 6:45 p.m. on the evening of 10/05/09, found the second cart for residents on the East wing contained Resident #12's meal tray. From 6:00 p.m. through 6:30 p.m., several members of the nursing staff went to the food cart that held Resident #12's tray and those of two (2) other residents; each of the staff members pulled out Resident #12's tray, looked at it, and then put it back in the food cart. The staff members then went to other residents who were finished with their meals and picked their trays, ignoring Resident #12's dinner tray. At 6:35 p.m., Employee #61 (a nursing assistant) picked up the resident's tray and took it into the resident's room. Further observations Resident #12 in a low bed in her room. Employee #61 attempted to pull the resident up in the bed, but the bed was unable to be raised. Employee #61 then pulled the resident into a sitting position and had to hold the resident in a sitting position while attempting to manually adjust the head of the bed. Employee #61 then brought an overbed table into the resident's room from an adjacent room and put the resident's meal tray on the overbed table. The nursing assistant then fed the resident by standing over top of her and lowering the food to the resident's mouth. 2. During observations on the mid-afternoon of 10/07/09, with the director of nursing (DON) and an occupational therapist, two (2) nursing assistants (NAs - Employees #56 and #68) sat the resident on the… | 2015-02-01 |
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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 );