cms_WV
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46 rows where "inspection_date" is on date 2010-12-09
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Suggested facets: facility_name, facility_id, address, city, zip, 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10621 | 10621 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 156 | D | 0 | 1 | GCMN11 | . Based on record review and staff interview, the facility failed, for one (1) of two (2) applicable residents / responsible parties, to provide notice of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. Resident identifier: #3. Facility census: 83. Findings include: a) Resident #3 During the morning of 12/08/10, records were reviewed for three (3) residents whose Medicare-covered services had been discontinued by the facility. At the same time, interviews were conducted with facility corporate office personnel who were assisting with bookkeeping responsibilities in the absence of the facility's bookkeeper. Record review revealed Resident #3's Medicare-covered services were discontinued on 09/16/10, because he had reached his maximum potential in occupational therapy services. The corporate persons were unable to locate evidence Resident #3 received a notice his Medicare services were discontinued, and no evidence the resident / responsibility party had been given the opportunity to request a demand bill. On 12/09/10, the facility's bookkeeper (Employee #18) searched her records for evidence that the appropriate notices had been given to Resident #3. During the morning of 12/09/10, Employee #18 reported the "cut letter" and opportunity to request a demand had not been provided this resident / responsible party. . | 2015-01-01 |
| 10622 | 10622 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 159 | B | 0 | 1 | GCMN11 | . Based on resident and staff interview, the facility failed to assure residents had access to their funds on weekends and/or at other times the business office was closed. This practice had the potential to affect all residents for whom the facility managed funds. At the time of the survey, the facility maintained a trust fund for sixty-nine (69) residents. Facility census: 83. Findings include: a) During Stage I confidential resident interviews on 11/29/10 and 11/30/10, four (4) residents described that their personal funds were not available on weekends and/or at other times the business office was not open. On 12/08/10 at 2:00 p.m., an interview was conducted with the business office staff member who assists in resident funds. At that time, this staff member described that, prior to 11/30/10, residents had not been able to get funds except during business office hours. This person stated that, on that date, resident funds became available to residents at times the business office was closed, by means of a small amount of money provided to nursing personnel for this purpose. . | 2015-01-01 |
| 10623 | 10623 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 167 | C | 0 | 1 | GCMN11 | . Based on observation and staff interview, the facility failed to assure the facility's survey results were posted in an area that was accessible to all residents. The results that were in the posting did not include the deficiencies cited during complaint investigations that were conducted since the facility's last standard annual survey. This practice had the potential to affect all residents who desire to review the facilities survey results. Facility census: 83. Findings include: a) Observation of the facility's publicly posted information, on the morning of 12/01/10, found the facility's survey results were posted between the two (2) front double doors in an area where most of the residents were not permitted. Review of the survey results that were posted found they did not contain the results of complaint investigations that had been conducted since the facility's last standard annual survey, during which the facility was cited deficiencies. The administrator was notified of this finding at 12:45 p.m. on 12/08/10. She verified the survey results that were posted were not complete and were not posted in an area that was accessible to all residents. . | 2015-01-01 |
| 10624 | 10624 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 241 | D | 0 | 1 | GCMN11 | . Based on observation, the facility failed to ensure one (1) of eighteen (18) residents seated in the dining room for the evening meal on 11/29/10 was treated in a dignified or respectful manner as he waited for his meal. The resident was ignored by staff when he asked for assistance with drinking the orange beverage which had been placed in front of him. Resident identifier: #10. Facility census: 83. Findings include: a) Resident #10 On 11/29/10 at 5:05 p.m., this resident was seated in the dining room when a refreshment cart was brought to the room by staff members. An orange beverage was placed in front of the resident. The resident was unable to grasp or drink the beverage without assistance, and he requested assistance with drinking from staff. Four (4) different staff members passed by the resident and failed to acknowledge the resident or his request. The fifth time the resident asked for a drink, a nurse stopped and told the resident he could not have his beverage until his special cup came out on his tray. On the resident's sixth request to get a drink, another staff member stopped what she was doing, acknowledged the resident's request, and assisted him in drinking the beverage. It should be noted that the resident's tray, with the special cup, was not served the resident until after 5:30 p.m. . | 2015-01-01 |
| 10625 | 10625 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 242 | D | 0 | 1 | GCMN11 | . Based on resident interview, medical record review, and staff interview, the facility failed to assure one (1) of thirty-two (32) Stage II sample residents was provided showers as she desired, on her scheduled shower days. Resident identifier: #32. Facility census: 83. Findings include: a) Resident #32 During Stage I resident interviews on 11/30/10 at 3:29 p.m., this resident described she was not receiving her showers as scheduled. The resident stated she was scheduled for showers on Mondays and Thursdays, but these showers were not always provided by staff. Further interview revealed the showers were not provided on other days, if they happened to be missed on Mondays and Thursdays. The resident's choice was for her showers to be provided twice weekly and on Mondays and Thursdays as scheduled. On 12/06/10 at 4:45 p.m., this resident's nursing assistant flow sheets were reviewed. As stated by the resident, she was scheduled for showers on Mondays and Thursdays on the 3-11 shift. Review of the October, November, and December 2010 records revealed the resident was not provided showers on the following Mondays: 10/04/10, 11/08/10, and 11/25/10. Additionally, she was not provided showers on the following Thursdays: 11/11/10, 11/25/10, and 12/02/10. (There was one (1) refusal on a scheduled shower day in October, and this day was not counted in the assessment of showers provided.) This information was brought to the attention of the director of nursing (DON). During the morning of 12/09/10, the DON reported she was unable to locate any information which disputed the showers had not been given as scheduled. . | 2015-01-01 |
| 10626 | 10626 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 244 | E | 0 | 1 | GCMN11 | . Based on a review of the resident council meeting minutes and staff interview, the facility failed to assure requests made by residents during the monthly resident council meeting were acted upon. During the October 2010 resident council meeting, the residents asked to have copies of the meal menus posted in their rooms. No action was taken to comply with this request as of 12/09/10. This practice has the potential to affect more than an isolated number of residents. Facility census: 83. Findings include: a) According to the October 2010 resident council meeting minutes, the residents in attendance verbalized that they would like to have menus of the meals posted in their rooms. The response from the facility's dietary department was that they would post them as soon as the menus changed. As of the 12/09/10, the menus were still not posted in the residents' rooms, and there was no further response to the council members' request. . | 2015-01-01 |
| 10627 | 10627 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 253 | D | 0 | 1 | GCMN11 | . Based on observation and staff interview, the facility failed to provide maintenance services to maintain a comfortable interior for the residents. Observation found the corridors to rooms #153 and #101 were not properly functioning and would not remain open, and the corridor door to room #158 had scratched / splintered pealing wood on the door. This practice affected three (3) of thirty-two (32) doors to residents' rooms. Facility census: #83. Findings include: a) Room #153 Observation found the corridor door to this room was closed on multiple occasions throughout the first week of the survey. When observed at 10:00 a.m. on 12/08/10, the door was propped open with a trash can. When the trash can was moved, the door automatically went shut on its own and would not remain open. b) Room #101 Observation found the corridor door to this room was propped open with a trash can on 12/08/10. When the trash can was moved by this surveyor, the door would not remain open but, instead, closed on its own. c) Room #158 Observation found the corridor door to this room had peeling wood that was splintered on the edges of the door. d) Employee #22 (the maintenance supervisor) was made aware of the issues with these three (3) doors at 1:00 p.m. on 12/09/10. He verified the doors were in need of repair at that time and stated he would address them. . | 2015-01-01 |
| 10628 | 10628 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 272 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to assess one (1) of thirty-two (32) Stage II sample residents for his continued need for thickened liquids. Resident identifier: #10. Facility census: 83. Findings include: a) Resident #10 During the evening meal observation on 11/29/10, this resident was provided an orange beverage which was of regular consistency. Observation revealed no coughing, choking, or strangling as the resident drank the beverage. At that time, it was not known that the resident had a physician's orders [REDACTED]. On 12/07/10, review of the resident's medical record found a physician's orders [REDACTED]. There was a speech therapy assessment, dated 11/11/09, which indicated a need for honey thick liquids. There was no evidence of a more current speech therapy assessment. Additionally, on 03/18/10, the facility had a "hold harmless" form completed by the appropriate representative, so the resident could drink regular "Coca Cola". On 12/08/10 at 1:30 p.m., an interview regarding this resident was conducted with the director of nursing (DON). After hearing the resident drank thin liquids without evidence of a problem on 11/29/10, the DON confirmed a new speech therapy evaluation was indicated. . | 2015-01-01 |
| 10629 | 10629 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 280 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to review and revise Resident #115's plan of care to reflect the diet that was being provided by the facility. The resident had dietary restrictions ordered by her physician and included in her care plan that restricted the use of added salt. Observation found she received a package of salt on her meal tray, and staff added the salt to her food. The facility did not assure the resident's care plan was revised to include the resident's wishes and refusal to eat meals without salt. This was observed for one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #115. Facility census: 83. Findings include: a) Resident #115 Review of Resident #115's medical record found, on the monthly recapitulation of physician orders [REDACTED]. Observations were made of this resident eating lunch at 12:15 p.m. on 12/02/2010. She had a package of salt on her tray. The restorative nursing assistant (Employee #94) opened the salt packet and sprinkled it on the resident's food. Resident #115 ate some of her lunch in the restorative dining program, then she was fed by the staff. Employee #94, when interviewed regarding the salt, she said this resident will not eat food without adding salt. "If you do not salt it, she will send you after the salt before she will eat the food." She stated they started just sending it on her tray, because staff would have to go get it anyway. The medical record was reviewed again, and there was no evidence that the resident's non-compliance with her no added salt diet had been recorded and addressed with the physician. The director of nursing (DON), when interviewed on the afternoon of 12/02/10 regarding this resident's diet, verified that, according to the physician's orders [REDACTED]. She agreed the care plan should have been revised to address the resident's non-compliance with her diet instead of just going ahead and sending her salt.… | 2015-01-01 |
| 10630 | 10630 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 282 | D | 0 | 1 | GCMN11 | . Based on observation, medical record review, and staff interview, the facility failed to implement the current care plan for one (1) of thirty-two (32) Stage II sample residents. The facility did not implement the resident's care plan for thickened liquids. Resident identifier: #10. Facility census: 83. Findings include: a) Resident #10 During observation of a pre-meal activity prior to the evening meal on 11/29/10, this resident was provided an orange beverage which was of regular consistency. Observation revealed a nursing staff member assisted the resident in drinking this beverage. On 12/07/10, the resident's medical record was reviewed. The resident had current care plan approaches to "Provide honey thickened liquids" and "Encourage resident to drink thickened liquids only." The resident was provided the thin liquids at his table on 11/29/10. When assisting the resident to drink the beverage, nursing staff did not mention to the resident that the beverage was not thickened and/or provide the resident with a beverage of the proper consistency. On 12/08/10 at 1:30 p.m., an interview regarding this resident was conducted with the director of nursing (DON). At that time, the DON confirmed the care plan should have been followed and the resident should have had thickened liquids at the pre-meal activity. . | 2015-01-01 |
| 10631 | 10631 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 309 | D | 0 | 1 | GCMN11 | . Based on medical record review, review of the facility's bowel protocol, and staff interview, the facility failed to implement its bowel protocol for one (1) of thirty-two (32) Stage II sample residents. Additionally, the facility failed to assure this resident, who had serious problems with constipation, had an individually written bowel protocol. The facility's protocol called for interventions beginning when a resident did not have a bowel movement (BM) in three (3) days. This resident was not provided interventions until nine (9) days when indicated on one (1) occasion and six (6) days when indicated on another occasion. Resident identifier: #5. Facility census: 83. Findings include: a) Resident #5 Medical record review, on 12/07/10, revealed a nursing note dated 10/06/10 at 7:10 a.m., which stated, "Resident given enema d/t (due to) (symbol for 'no') BM's (bowel movements) charted for 9 days." Continued review of the record, including the medication administration records (MARs) and BM records revealed no interventions prior to the enema, which was given after nine (9) consecutive days with no BM. Another nursing note, on 11/10/10 at 10:00 p.m., stated, "Resident on day 6 of BM (without a bowel movement for 6 days). MOM (milk of magnesia) given..." Continued review of the record, including the MARs and BM records, revealed no interventions prior to the MOM which was given after six (6) consecutive days with no BM. The facility had standing orders, which were called "Routine Protocol" with a revision date of November 2006. A copy of this protocol was in the resident's medical record. This routine protocol contained a protocol for constipation, which stated: "The BM record should be checked daily on 3-11 shifts. If a resident has not had a BM in 3 days, give MOM 30 cc PO (by mouth) at H.S. (bedtime). On the third day force fluids unless contraindicated, at least 2000 cc/24 hours. If no results from MOM administration, then the next morning of the fourth day 7-3 shift the resident needs to be checked for pres… | 2015-01-01 |
| 10632 | 10632 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 312 | D | 0 | 1 | GCMN11 | . Based on family interview, resident interview, staff interview, and observation, the facility failed to assure one (1) of thirty-two (32) Stage II sample residents received necessary services to maintain good personal hygiene. This resident, who was unable to perform her own activities of daily living, had dry, flaky feet and long, jagged, dirty fingernails. Resident identifier: #5. Facility census: 83. Findings include: a) Resident #5 On 12/06/10, a family interview was conducted with this resident's sister. During this interview, the sister expressed concern that the resident's feet were not routinely cleaned by facility staff. She stated the resident's feet were often dry and flaky, and that she (the sister) often soaked and cleaned them herself. Interview with the resident, at 1:00 p.m. on 12/07/10, revealed her feet were always cold, so she wore socks all the time. Further interview revealed the resident was rarely showered due to her severe pain, and she preferred bed baths. Upon inquiry, the resident stated she did not feel her feet received the care they required, and that her sister often had to soak them and clean them. She stated staff did not perform this care routinely. Review of the resident's care plan, on 12/07/10, revealed no specific care plan regarding the resident's foot care. On 12/08/10 at 9:00 a.m., this resident's feet were observed with a registered nurse (Employee #20). The resident's feet were dry and flaky. According to Employee #20, the resident needed foot care. Employee #20 stated she would assure the resident received this care. During this observation, the resident's fingernails were noted to be long, jagged, and dirty. The resident's care plan indicated the resident liked long fingernails. Upon inquiry, the resident confirmed she liked long fingernails, but she looked at her nails and stated, "Not this long. They need trimmed." . | 2015-01-01 |
| 10633 | 10633 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 323 | E | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to maintain an environment free of accident hazards for two (2) of thirty-two (32) Stage sample residents. Resident #90 was observed on several occasions wearing socks without non-skid soles, when he was care planned to wear non-skid sole shoes. Resident #10 was observed drinking thinned liquids, when he was ordered thickened liquids. Also, on the East Wing in the shower room, a shower chair was found sitting in the corner with rusted wheels that were in poor condition. This shower chair, which was available for use, presented an accident hazard to more than an isolated number of residents. Resident identifiers: #90 and #10. Facility census: 83. Findings include: a) Resident #90 On 11/29/10 at 3:50 p.m., the resident was observed in the activities room, propelling himself in wheelchair and wearing white socks without non-skid soles. The resident was again observed propelling himself in wheelchair on 11/30/10 at 2:00 p.m., wearing white socks without non-skid soles. On 12/01/10, 12/02/10, 12/06/10, 12/07/10, and 12/08/10, the resident was observed propelling himself in wheelchair wearing white socks with non-skid soles. Review of the resident's care plan revealed he was to wear non-skid sole shoes due to risk of falls. An interview with a licensed practical nurse (LPN - Employee #5) revealed the resident was capable of transferring himself without assistance from the bed to the wheelchair, and he also ambulated to the restroom occasionally without assistance. On 12/08/10 at 1:30 p.m., an interview with registered nurse (RN - Employee #70) revealed she was unaware if the resident had a pair of non-skid sole shoes, but she would put some non-skid socks on the resident. An observation, on 12/08/10 at 4:00 p.m., found the resident was wearing non-skid socks while propelling himself down the hallway. b) Resident #10 During observation of a pre-meal activity prior to the… | 2015-01-01 |
| 10634 | 10634 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 325 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to assure feeding recommendations made by the speech-language pathologist (SLP) for Resident #115 were implemented as written. The facility also failed to assure the diet ordered by the physician was followed and that the physician was notified when the resident was non-compliant with the diet, to see if the diet order could be changed. This resident had a history of [REDACTED]. This practice affected one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #115. Facility census: 83. Findings include: a) Resident #115 Review of Resident #115's medical record found, on the monthly recapitulation of physician orders [REDACTED]. Further review of the record found a speech therapy evaluation and recommendations made by the SLP on 11/12/10. The SLP stated the goal for this resident was "to decrease risk of aspiration and increase PO (by mouth) intake". The recommendations included: placement of the resident in the restorative feeding program; she was not to have straws in her drinks, she was to be provided verbal cueing to swallow with her meals due to her issue of pocketing food in her mouth; and she was to have two (2) to three (3) bites of food alternated with one (1) drink. Further review of the medical record revealed that, when the resident was admitted to the facility on [DATE], her weight was 103#. Her weight on 09/01/10 was 116#. The resident's weight on 10/01/10 was 113#. The resident's weight on 11/15/10 was 107#. This represented a weight loss of 9# in two (2) months and 6# in one (1) month. Observations were made of this resident eating lunch at 12:15 p.m. on 12/02/2010. She had a package of salt on her tray. The restorative nursing assistant (Employee #94) opened the salt packet and sprinkled it on the resident's food. Resident #115 ate some of her lunch in the restorative dining program, then she was fed by the staff. She had a straw in… | 2015-01-01 |
| 10635 | 10635 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 332 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, review of the facility's drug handbook, and staff interview, the facility failed to ensure that it was free of medication error rates of five percent (5%) or greater. Out of fifty-one (51) medication opportunities, there were three (3) errors observed. This resulted in an error rate of five and eighty-eight-one hundredths percent (5.88%). This practice effected three (3) of ten (10) residents. Resident identifiers: #50, #43, and #42. Facility census: 83. Findings include: a) Resident #50 During medication pass on 12/06/10 at 1:50 p.m., a registered nurse (RN - Employee #75) was observed to administer eye drops to Resident #50. The physician's orders [REDACTED]. Employee #75 was observed to administer one (1) gtt (drop) to both eyes. When questioned about the eye drops and why they were administered to both eyes, Employee #75 stated this was how the resident wanted it. She agreed the physician needed to be contacted to have the order changed. -- b) Resident #43 During medication pass on 12/07/10 at 9:20 a.m., an RN (Employee #77) administered an inhaler "[MEDICATION NAME] Diskus 1 (one) puff" to Resident #43 and then told the resident to get herself a drink. Employee #77 was questioned about the use of the inhaler and asked if she instructed residents to rinse and spit after this inhaler was administered. The RN stated she had never been told that they had to spit; she just had them to get a drink to rinse out their mouth. She was asked, at that time, to refer to the manufacturer's instructions in the package insert accompanying the box containing the [MEDICATION NAME] Diskus. It was noted that the [MEDICATION NAME] was in a plastic bag with a label for the use on the bag, but there was no box or manufacturer's instructions included. The nurse was asked for the facility's drug reference book used by the nurses to research the medications that are administered. There were no instructions in the drug book f… | 2015-01-01 |
| 10636 | 10636 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 353 | F | 0 | 1 | GCMN11 | . Based on review of the facility's nursing schedules and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each shift. According to facility staff, nursing employees "know" who the charge nurse is, but this person is not designated as required by this regulation. This practice has the potential to affect all facility residents. Facility census: 83. Findings include: a) Review of the facility's nursing schedules revealed a licensed nurse was not designated to serve as the charge nurse on each shift. The staff development coordinator (Employee #109) stated, at 9:30 a.m. on 12/07/10, the facility has "never designated a person in charge, they just know." . | 2015-01-01 |
| 10637 | 10637 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 356 | C | 0 | 1 | GCMN11 | . Based on observation and staff interview, the facility failed to assure the required information regarding nursing staffing was posted at the beginning of each shift. The census and/or the hours actually worked were not posted in a clear and readable format. Seventeen (17) days was reviewed, and there were twenty (20) shifts for which no information was available on these postings. This information is provided so residents and the public can review the facility's staffing patterns at any given time. The practice of not posting complete and accurate information has the potential to affect all residents and visitors who would like to review the staffing. Facility census: 83. Findings include: a) Observation of the facility's posting of nurse staffing data, on 12/08/10 at 10:30 a.m., found it did not contain the hours actually being worked at that time. The posting is required to be updated at the beginning of each shift; therefore, this posting should have been completed at 7:00 a.m. Further review of the facility's nurse staffing data sheets found there were twenty (20) shifts in the last seventeen (17) days that had not been posted. The staffing sheets did not record the census at the beginning of each shift and the actual hours worked by the nursing staff responsible for care per shift. The registered nurse supervisor (Employee #20) was made aware that the posting was not being completed as required. . | 2015-01-01 |
| 10638 | 10638 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 371 | F | 0 | 1 | GCMN12 | . Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 84. Findings include: a) During observation of the dietary department with the dietary manager (DM - Employee #63) on 02/22/11 at 3:15 p.m., the following sanitation infractions were identified: 1. The drain of the handwashing sink was too slow to drain quickly enough to prevent hands from coming in contact with the water as hands were being washed. 2. There was no waste receptacle, which was touch free, at the handwashing sink to dispose of paper towels after washing hands. 3. The large blue soup / cereal bowls contained debris which could be scraped off with a fingernail. When observed, the DM took a bowl into the dish room and used a non-scratch abrasive sponge on a bowl. The debris was removed by this method. 4. Clear beverage containers were not air dried prior to lids being placed on them and lids for the pellet system were stacked with moisture between them. The trapped moisture in these items created a potential for bacterial growth. 5. Clean plates were placed in the plate warmer prior to cleaning crumbs and debris from the warmer. 6. The underneath of the clean silverware rack contained a greasy / dusty debris which was able to be removed upon touch. The facility's food handler gloves were stored under this silverware rack. -- b) On 02/24/11 at 1:00 p.m., a dietary employee (#92) was observed serving a meal. He touched his face around his nose and mouth with his gloved hand, then immediately resumed serving food without changing his gloves and washing his hands. -- c) On 03/02/11 at 12:55 p.m., a meal tray, which was tested for temperatures in the presence of the DM, revealed the colesl… | 2015-01-01 |
| 10639 | 10639 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 425 | D | 0 | 1 | GCMN11 | . Based on observation, review of the facility's drug reference handbook, and staff interview, the facility failed to assure the pharmaceutical services provided to residents included assuring that staff had the proper instructions available for administering medications ordered by the physician. There were no instructions available in the facility to instruct the nurse of the proper administration of Advair Diskus. The medication did not come from the pharmacy in its original container, and there were no manufacturer's instructions available and no instructions in the facility's drug reference handbook. The nurse instructed the resident to take a drink instead of instructing the resident to rinse her mouth following the administration of the Advair Diskus inhaler. This affected one (1) of one (1) resident observed to receive this type of inhaler. Resident identifier: #43. Facility census: 83. Findings include: a) Resident #43 During medication pass on 12/07/10 at 9:20 a.m., an RN (Employee #77) administered an inhaler "Advair Diskus 1 (one) puff" to Resident #43 and then told the resident to get herself a drink. Employee #77 was questioned about the use of the inhaler and asked if she instructed residents to rinse and spit after this inhaler was administered. The RN stated she had never been told that they had to spit; she just had them to get a drink to rinse out their mouth. She was asked, at that time, to refer to the manufacturer's instructions in the package insert accompanying the box containing the Advair Diskus. It was noted that the Advair was in a plastic bag with a label for the use on the bag, but there was no box or manufacturer's instructions included. The nurse was asked for the facility's drug reference book used by the nurses to research the medications that are administered. There were no instructions in the drug book for the proper use of the Advair Discus. During an interview with the facility's consultant pharmacist on the afternoon of 12/07/10, she was asked about the correct way to adminis… | 2015-01-01 |
| 10640 | 10640 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 431 | E | 0 | 1 | GCMN11 | . Based on observation and staff interview, the facility failed date open medications in accordance with current standards of practice. This deficient practiced has the potential to affect more than an isolated number. Facility census: 83. Findings include: a) On 11/29/10 at 2:30 p.m., an observation was made in the East Wing medication storage room, in the company of a licensed practical nurse (LPN - Employee #5) revealed a vial of influenza vaccine with no date was found open in the medication storage refrigerator. With a date to reflect when this vial was opened, it was not possible to determine when the contents of the vial were no longer safe for use. . . | 2015-01-01 |
| 10641 | 10641 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 441 | E | 0 | 1 | GCMN12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, staff interview, and policy review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help help prevent the transmission of disease and infection, by failing to immediately implement transmission-based precautions when Resident #38 returned from a hospital stay with a [DIAGNOSES REDACTED]. These practices had the potential to affect all residents in the facility. Facility census: 84. Findings include: a) Review of Resident #38's medical record revealed a discharge summary from a local hospital, dated 02/17/11, with a discharge [DIAGNOSES REDACTED]. Review of Resident #38's facility admission orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. A nurse's note, dated 02/18/11 at 3:00 a.m., revealed the resident remained on antibiotic therapy due to a positive Clostridium difficile culture. A nurse's note, dated 02/18/11 at 12:00 p.m., revealed the resident changed rooms due to positive Clostridium difficile with five (5) days of antibiotic therapy remaining. An interview with Employee #64, on 03/01/11, revealed Resident #38 was placed in isolation "a little before 12:00 p.m. on 02/18/11." Employee #64 also stated the resident returned to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Review of the facility policy regarding "Isolation - Categories of Transmission - Based Precautions" revealed contact precautions should be implemented "for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. ... Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids (e.g. the individual is incontinent on the floor, or wanders and touches others)." Re… | 2015-01-01 |
| 10642 | 10642 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 463 | D | 0 | 1 | GCMN11 | . Based on observation, resident interview, and staff interview, the facility failed to assure residents' rooms were equipped with functioning nurse call systems. Room #123 had a private bathroom that had no string on the call bell system to ring if the occupant of the room fell . This resident took her self to the bathroom and stated she had to reach up and push the button, because there was no string on her call light. This practice was found to be true for one (1) of forty (40) call lights observed. Facility census: 83. Findings include: a) During a tour of the environment on 12/10/10, observation of Room #123 found the private bathroom did not have a string on the call light. Without the string, if the resident were to fall in the bathroom, she would not be able to call for assistance. During an interview with the resident on the morning of 12/10/10, she stated she uses that call bell, but she has to reach up and push the button because there is no string. A registered nurse (RN - Employee #20) was made aware that this call light did not have a string to pull in case of an emergency at 11:30 a.m. 12/10/10. . | 2015-01-01 |
| 10643 | 10643 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 318 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, and staff interview, the facility failed ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM, as evidenced by the facility's failure to ensure a resident wore a splint ordered by a physician. One (1) of forty (40) residents on the Stage I sample was affected. Resident identifier: #85. Facility census: 83. Findings include: a) Resident #85 During the Stage I information gathering phase of the survey, staff reported this resident was supposed to wear a splint to her left hand. An observation, during Stage I on 11/30/10 at 3:24 p.m., revealed the resident did not have a splint in place. On 12/18/10 at 4:15 p.m., review of the resident's December 2010 physician's orders [REDACTED]." This order originated on 05/27/10. At 10:40 a.m. on 12/09/10, an observation revealed the resident, again, did not have a splint in place. On 12/09/10 at 10:45 a.m., an interview with a registered nurse (RN - Employee #70) revealed the resident had not worn the splint for approximately one (1) week. Employee #70 stated that staff oftentimes forgot to put the splint on the resident, but if they did, the resident often took it off. Review of the resident's nursing notes revealed no entries stating that staff had attempted to place the splint on the resident's left hand. Further review of the nursing note revealed no entries stating that the resident refused to wear the splint. . | 2015-01-01 |
| 10644 | 10644 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 492 | C | 0 | 1 | GCMN11 | . Based on staff interview and review of individual food service workers' permits, the facility was not in full compliance with local laws regarding food handler's cards. One (1) of ten (10) dietary employees, who was currently working, had an expired food handler's card. This is a local requirement for the county in which the facility is located. This practice had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 83. Findings include: a) During the survey, each dietary employee's food handler's card was reviewed. No card was available for Employee #111. The dietary manager (Employee #68) was asked to determine if Employee #111 had a current food handler's card. Employee #68 reported that Employee #111's food handler's card was expired and that she was now scheduled to renew the card. . | 2015-01-01 |
| 11338 | 11338 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2010-12-09 | 225 | D | 9K0R11 | . Based on review of abuse / neglect policies, review of employees' personnel files, and staff interview, the facility failed make reasonable efforts to uncover information about any past criminal prosecutions to assure that individuals are not employed who have been potentially found guilty of abusing, neglecting, or mistreating residents by a court of law for one (1) of seven (7) employee personnel records reviewed. Facility census: 115. Findings include: a) The facility was entered at 12:15 p.m. on 12/09/10, to conduct an unannounced complaint investigation alleging that the facility did not perform necessary screening for potential employees to rule out criminal convictions that would make them unfit for service in a nursing facility. Review of the facility's policy addressing the prevention of resident abuse / neglect "1.0-WV Abuse Prohibition" (revised 11/01/09) found the following under the section entitled "Process": "2. The Center will screen potential employees for a history of abuse, neglect, or mistreating residents... "2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service...". Review of the personnel file for nursing assistant (NA) #1 found she had previously worked in the Commonwealth of Virginia. The personnel file contained no evidence to reflect the facility made a reasonable effort to determine whether this individual had criminal convictions in Virginia which would render him / her unfit to work in a long term care facility. An interview with the administrator, on 12/09/10 at 3:10 p.m., confirmed the facility had no evidence that NA #1 had been screened for criminal convictions in Virginia. | 2014-04-01 | ||
| 11339 | 11339 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 157 | D | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to notify a resident's legal representative when they commenced a new form of treatment. One (1) of six (6) sampled residents was initiated into the fine dining program and the walk-to-dine program (during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts), with no evidence of family notification of this change in treatment or what it involved. The resident, who was seated in a regular chair at a table in the dining room without safety devices, got up from the chair by herself and fell to the floor, sustaining significant injury. The family of the resident was not informed that the use of these safety devices would not be permitted during fine dining and/or the walk-to-dine program. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. The was also revealed no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: "Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chai… | 2014-04-01 | ||
| 11340 | 11340 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 280 | D | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to revise a care plan for one (1) of six (6) sampled residents when she was initiated into the facility's newly established walk-to-dine and fine dining programs, during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts. Resident #111, who had an order for [REDACTED]. needs while in the walk-to-dine / fine dining program. Resident identifier: #111. Facility census: 110. Findingd include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. There was also no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safet… | 2014-04-01 | ||
| 11341 | 11341 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 323 | G | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to develop and implement written policies and procedures to ensure that residents receive care and services necessary to prevent avoidable accidents This was evident for one (1) of six (6) sampled residents whose treatment was changed without a physician's orders [REDACTED]. There was no evidence this resident (who had been identified as being at risk for falls) was first assessed to see if she was a candidate for removal of safety devices while in the dining program and no evidence of care planning for safety interventions to prevent accidents while participating in these programs. Additionally, there were no written guidelines or interventions for staff to follow to assure the resident's safety needs were met. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: "Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... "Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)." Review of the care plan revealed no evidence of plans to walk the resident to the dining room for th… | 2014-04-01 | ||
| 11342 | 11342 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 155 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure one (1) of seven (7) sampled residents (who had the capacity to understand and make a health care decision) was fully informed in advance of the nature of a surgical procedure (incision and drainage of a large hematoma); understood the possible consequences of the procedure; and was asked for a written consent prior to the undertaking of the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her re… | 2014-04-01 | ||
| 11343 | 11343 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 157 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure, for one (1) of seven (7) sampled residents, the physician was notified of an acute change of condition (the presence of a large hematoma), and failed to consult the physician and notify an interested family member prior to a significant alteration in treatment. Resident #118 (who had multiple comorbidities and was on anticoagulation therapy) developed a large hematoma on her left lower extremity, and the facility failed to notify the attending physician of the hematoma. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage) on the hematoma without consulting with the attending physician and without informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. The physician and the MPOA were contacted after the procedure resulted in significant bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her… | 2014-04-01 | ||
| 11344 | 11344 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 224 | G | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to assure one (1) of seven (7) sampled residents received appropriate services necessary to avoid physical harm. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a large hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on [DATE], she verified Resident #118 had capacity, a… | 2014-04-01 | ||
| 11345 | 11345 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 225 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to immediately report to State agencies and/or thoroughly investigate an incident involving the neglect of one (1) of seven (7) sampled residents. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. This event was reported to the State survey and certification agency as an "unusual occurrence" without evidence of a thorough investigation. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being … | 2014-04-01 | ||
| 11358 | 11358 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 323 | G | 777711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibi… | 2014-04-01 | ||
| 11359 | 11359 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 250 | D | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and interview with a hospital social, the facility failed to provide medically-related social services for two (2) of thirty-two (32) Stage II sample residents. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors and no planned medically-related social service interventions to address the behaviors. Resident #31 missed a medical appointment, because the facility did not remind him so that he was prepared in advance. Resident identifiers: #35 and #31. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of … | 2014-04-01 | ||
| 11360 | 11360 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 201 | D | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and interview with the social worker at the hospital, the facility failed to attempt to meet the needs of one (1) of six (6) sampled residents prior to planning his discharge from the facility. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. There was evidence the facility had no plans to readmit the resident after the evaluation. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causal factors and no planned intervention to address the behaviors. Evidence revealed the facility had prearranged for the resident to be transferred to a local hospital then be transferred to another facility out of state. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. O… | 2014-04-01 | ||
| 11361 | 11361 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 279 | E | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, staff interview, family interview, and resident interview, the facility failed to develop comprehensive care plans and/or interventions for four (4) of thirty-two (32) Stage II sample residents. There was no care plan for intentional weight loss for Resident #43; no care plan for foot care for Resident #5; no interventions for behaviors for Resident #35; and no restorative care plan for Resident #115. Resident identifiers: #43, #5, #35, and #115. Facility census: 83. Findings include: a) Resident #43 During an interview with the resident on 12/08/10 at 3:15 p.m., the resident revealed she was trying to lose weight, stating, "I really want to get rid of my belly." Review of the dietary progress notes, dated 08/26/10 and 09/29/10, revealed the registered dietician had noted the resident was trying to lose weight. Review of the dietary progress notes, dated 10/26/10, revealed the dietary supervisor (Employee #68) also noted: "Resident wants to lose wt (weight)." Review of the dietary progress notes, dated 11/30/10, revealed the dietary supervisor noted: "Resident wants to continue to lose wt per her choice due to history of diabetes." An interview on 12/08/10 at 2:15 p.m., with a registered nurse (RN - Employee #77), revealed the resident frequently requested junk food and had yet to mention to her (Employee #77) that she wanted to lose weight. Review of the resident's care plan found no mention of a plan to assist the resident in achieving intentional weight loss. b) Resident #5 On 12/06/10, a family interview was conducted with this resident's sister. During the interviewed, the sister expressed concern that the resident's feet were not routinely cleaned by facility staff. She stated the resident's feet were often dry and flaky, and that she (the sister) often soaked and cleaned them herself. Interview with the resident, at 1:00 p.m. on 12/07/10, revealed her feet were always cold, so she wore soc… | 2014-04-01 | ||
| 11362 | 11362 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 319 | D | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide appropriate treatment and services to assist one (1) of thirty-two (32) Stage II sample residents related to behavioral problems. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors for the behaviors. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from … | 2014-04-01 | ||
| 11363 | 11363 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 364 | F | GCMN12 | . Based on observation, test tray temperatures, and staff interview, the facility failed to assure foods were attractive, appetizing, and at the proper temperature when received by the residents. Pureed foods were thin and ran into each other on the plate for twenty (20) residents who were provided pureed diets. Additionally, the temperature of coleslaw was too warm for palatability, at the point of service, for all residents. These practices affected all facility residents who received nourishment from the dietary department. Facility census: 84. Findings include: a) On 02/24/11 during the noon meal, observations were made of residents eating in the activity room. The pureed foods (pinto beans, sauerkraut, and polish sausage) ran together touching each other on the plates. This created an unappetizing presentation for the twenty (20) residents who required pureed foods. There was no form to the foods at all. The foods on the plates were touching each other, edge to edge, with color being the only distinguishing factor from one food to the other. This was shown to the administrator (NHA - Employee #117) and the director of nursing (DON - Employee #118) at the time of the observation. The NHA confirmed the meals served to residents on pureed diets were not appetizing or attractive. -- b) At noon on 03/02/11, pureed meals were observed with the dietary manager (DM - Employee #63). The pureed broccoli mix and pureed ranch style beans were thin, without form, and ran into each other on the plates. At that time, the DM confirmed the foods should have form and not spread into each other. -- c) On 03/02/11 at 12:55 p.m., a test tray was requested to be placed on the cart immediately following the last resident to be served at the noon meal. There was a misunderstanding, and the cart on which the test tray was placed was not the last cart to be served. In addition, it contained only three (3) trays. The meals on this cart had no wait time for service; however, the foods were tested anyway, with the DM. The hot foods were… | 2014-04-01 | ||
| 11376 | 11376 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 157 | D | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the electronic medical record, staff interview, family interview, and incident report review, the facility failed to immediately inform the legal representative when one (1) of nine (9) sampled residents was involved in an incident requiring physician intervention. Resident #100, who had a history of [REDACTED]. After the son intervened, staff contacted the physician and Resident #100 was subsequently sent to the hospital where she was diagnosed with [REDACTED]. Facility census: 115. Findings include: a) Resident #100 On 11/16/10 at approximately 9:00 a.m., a family interview revealed Resident #100's son, who was also her legal representative, did not receive notification that his mother fell on [DATE] until he came to the facility on [DATE] and found a bruise on her shoulder. - Documentation on an incident report dated 10/16/10, when reviewed on 11/16/10 at approximately 1:00 p.m., revealed the nurse wrote, "As I was starting up the hallway, to do my med pass heard resident in (room #) yelling out. When entered the room and walked to her side (sic) she already started out of the bed on her arms before I got to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side." Documentation on the report related to notification of the resident's responsible party found the son was not notified of the fall until 5:00 p.m. on 10/17/10. - Review of Resident #100's electronic medical record, on 11/16/10 at approximately 2:00 p.m., revealed a nursing progress note identified as a "late entry" and dated 10/16/10 at 21:00 (9:00 p.m.) which stated, "As I was walking up the hallway to do my med pass. Writer heard resident yelling out. When entered the room and walked to her side. She already started out of the bed on her arms before I could get to her; the bottom half slithered out and onto the mat. Asked resident if she could get up and she attempted but went down onto her… | 2014-04-01 | ||
| 11377 | 11377 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 441 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the facility failed to fully implement appropriate measures to control the spread of scabies and to prevent possible re-exposure and re-infestation, in accordance with the facility's infection control policies and procedures and accepted standards of professional practice. These practices had the potential to result in more than minimal harm to all residents. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the handling of an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled "4.12 Scabies" (last revised on 02/01/10), the following process was to be implemented: "5 - Implement procedures to eliminate infestation and prevent transmissio… | 2014-04-01 | ||
| 11378 | 11378 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 490 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the governing body failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical well-being of all residents and others. The facility's administration failed to oversee and ensure the infection control policies and procedures were implemented as written to manage an outbreak of scabies and prevent transmission to others inside and outside the facility. This practice has the potential to cause more than minimal harm to all residents, staff, and visitors. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the governing body's failure to ensure the facility responded appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were… | 2014-04-01 | ||
| 11379 | 11379 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 520 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's infection control policies and procedures related to scabies, review of other facility documentation, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement appropriate plans of action to prevent the spread and re-infestation of scabies when a resident was diagnosed with [REDACTED]. The facility was aware of potential quality deficiencies associated with the implementation of policies and procedures to prevent the spread of scabies, as the facility was previously cited for non-compliance related to the facility's failure to respond appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. These practices had the potential to result in more than minimal harm to all residents. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled "4.12 Scabies" (last revised on 02/01/10), the following process was to be implemented: "5 - Implement procedures to eliminate infestation and prevent transmission to others. "5.1 - Use… | 2014-04-01 | ||
| 11380 | 11380 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 309 | G | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on incident report review, medical record review, staff interview, and family interview, the facility failed to ensure one (1) of nine (9) sampled residents received prompt medical attention following a fall from bed. The facility failed to contemporaneously collect and record physical assessment data following a fall (to identify possible injuries), failed to immediately notify the resident's family and physician of the fall, failed to communicate the fall to oncoming shifts so that staff would know to monitor the resident for possible sequelae of the fall, and failed to assess / monitor the resident after the fall to identify the need for, and obtain, medical intervention until after a family member intervened. On 10/16/10 at approximately 9:00 p.m., Resident #100 was said to have "slithered" out of her bed and onto the floor unassisted. The licensed practical nurse (LPN) who observed the incident (Employee #128) did not complete an incident report or document anything about the event in the resident's medical record at the time of the occurrence. She generated a "late entry" nursing note and an incident report (both dated 10/16/10), stating Resident #100 had no apparent injury related to the fall and no complaints of pain. When interviewed, Employee #128 admitted to not having completed a thorough assessment after the fall occurred on 10/16/10, and she admitted to not having documented anything about this fall (on either an incident report or in the nursing notes) until after the family's visit, which occurred on the evening of 10/17/10. No contemporaneous entries were made in the resident's nursing notes about Resident #100 having an injury until 6:20 p.m. on 10/17/10, when the nurse on duty at that time (Employee #34) recorded that the resident's son found a bruise on the resident's right shoulder that was dark purple in color; when interviewed, Employee #34 reported she had not been aware of the fall on 10/16/10 at the bruising … | 2014-04-01 | ||
| 11381 | 11381 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 514 | D | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to ensure the medical record of one (1) of nine (9) sampled residents was maintained in accordance with accepted standards of professional practice. Resident #100 was observed by a licensed practical nurse (LPN) having "slithered" out of her bed and onto the floor on the evening of 10/16/10. The LPN who witnessed this occurrence (Employee #128), when interviewed on 12/09/10, reported that she did not record an entry in the resident's nursing notes when the event occurred; rather, she recorded an entry in the nursing notes after the family noticed extensive bruising on the resident's shoulder during a visit on the evening of 10/17/10. The note, which was identified as a "late entry" and dated 10/16/10 at 21:00 (9:00 p.m.), did not contain any information to alert the reader that it was actually recorded after the fact, at a later date and time. Additionally, review of the resident's activities of daily living (ADL) flowsheet for October 2010 revealed blanks where the assigned nursing assistant should have recorded the amount of ADL assistance provided to the resident on the day shift (7:00 a.m. to 3:00 p.m.) on 10/17/10, and staff recorded "OOF" (out of facility) for the evening shift (3:00 p.m. to 11:00 p.m.) on 10/17/10, even though she did not leave the facility until 6:20 p.m. on that date. According to this resident's most recent minimum data set assessment, she was totally dependent on staff for all ADLs. Resident identifier: #100. Facility census: 115. Findings include: a) Resident #100 1. Review of facility records, conducted on 11/16/10 at approximately 11:00 a.m., revealed an incident report dated 10/16/10 for an event said to have occurred at 9:00 p.m. on 10/16/10 involving Resident #100. The report stated, "A… | 2014-04-01 | ||
| 11474 | 11474 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 328 | D | 6HW412 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure one (1) of ten (10) sampled residents received the maximum benefit of each aerosolized treatment ordered by her physician. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's order permitting her to self-administer the aerosolized treatments; however, there was no evidence the interdisciplinary team completed an assessment to ensure the resident was capable of reliably self-administering these treatments, and this self-administration of aerosolized medications was not addressed on her care plan. Licensed nursing staff was aware Resident #111 did not self-administer these treatments in an effective manner, and they did not provide additional monitoring / supervision to ensure she received the maximum benefit of each treatment. Additionally, licensed nursing staff did not complete pre- and post-treatment assessments that would allow them to determine whether the treatments were effective. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the med… | 2014-02-01 | ||
| 11475 | 11475 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 280 | D | 6HW412 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed, for one (1) of ten (10) sampled residents, to revise the resident's care plan to address her self-administration of aerosolized medications after an order was received from her physician to permit this. Resident #111, whose [DIAGNOSES REDACTED]. She had a physician's orders [REDACTED]. Resident identifier: #111. Facility census: 113. Findings include: a) Resident #111 1. Observation, during tour on 12/06/10 at 2:10 p.m., found Resident #111 sitting in her room holding a medicine cup attached to a nebulizer. The medicine cup had a small amount of liquid in it. The resident stated she needed her breathing treatment set up, that she was supposed to have received it at 1:00 p.m. The resident stated she asked both a nursing assistant and her nurse (Employee #21, a licensed practical nurse - LPN) for the treatment. In an interview on 12/06/10 at 2:15 p.m., Employee #21 said she set up the treatment for [REDACTED]. She reported the resident does the treatment herself after the nurse sets up the treatment, which includes putting the medication into the medicine cup. The resident then hits the button to turn on the machine when she is ready and self administers the treatment. The nurse then accessed the medication cart and took out Atrovent and [MEDICATION NAME] and went to the resident's room to set up the medication for Resident #111. -- 2. A physician's orders [REDACTED]." An earlier order, dated 08/05/10, stated the resident was to receive Atrovent 2% Inhaler, one (1) unit dose every four (4) hours administered via nebulizer, give with [MEDICATION NAME]; and [MEDICATION NAME] 0.083%, one (1) unit dose every four (4) hours administered via nebulizer, give with Atrovent. Review of the resident's December 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -- 3. Review of the resident's care… | 2014-02-01 |
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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 );