cms_WV
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text ▼ | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10524 | 10524 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2011-10-26 | 386 | D | 1 | 0 | 9O4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the attending physician signed all documents in the resident's medical record on each visit for one (1) of thirteen (13) sampled residents. Resident #92 was admitted to the facility on [DATE], with re-admitted s of 06/23/11 and 10/21/11. Medical record review, on 10/24/11, disclosed the resident's capacity determination statement and Physician's Orders for Scope of Treatment (POST) form had not been signed and dated by the attending physician during visits as required. Resident identifier: #92. Facility census: 108. Findings include: a) Resident #92 Medical record review, on 10/24/11, disclosed the attending physician had not signed and dated the resident's capacity determination statement and POST form which were in the medical record. Review of physician progress notes [REDACTED]. When brought to the attention of the facility, these forms were faxed to the physician's office to be signed and dated. During an interview conducted on 10/26/11 at 10:45 a.m., the director of nursing (Employee #88) confirmed these documents had not been signed by the attending physician. . | 2015-02-01 |
| 11477 | 11477 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2010-10-14 | 280 | D | LTYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the care plan of one (1) of four (4) sampled residents was revised to reflect the resident's current problems and needs. The lack of an updated care plan resulted in a lack of goals and interventions to address the most current issues facing the resident. The facility had relocated the resident to a different area of the building in a room by himself, and the care plan failed to address this change in environment and the potential negative impact it could have on the resident. Resident identifier: #28. Facility census: 86. Findings include: a) Resident #28 Record review revealed a social work progress note documenting Resident #28's move to a room on second floor on 09/02/10, due to safety concerns surrounding his aggressive behaviors towards other residents. The resident had spent approximately ten (10) days in an inpatient acute psychiatric hospital from 08/03/10 through 08/13/10, due to increased aggressive behaviors. On 09/02/10, the facility moved Resident #28 to a semi-private room without a roommate on second floor, in order to ensure the safety of other residents and to monitor Resident #28's behavior. The facility also placed an alarm on a gate across the doorway which would sound when the resident came in and out of his room during the night time hours. Resident #28 came to the facility in February 2008. He had lived in a room on first floor with two (2) other roommates for over two (2) years. Due to his increased negative behaviors and the guardian's lack of acceptance of alternatives to promote the safety of the roommates (such as the use of a bed alarm on Resident #28 to alert staff when he was transferring out of bed), the facility elected to move the resident to ensure safety of others and to monitor for further agitation and negative behaviors. After the resident went to live on second floor, the facility failed to revised his care plan to addr… | 2014-02-01 | ||
| 9930 | 9930 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-06-01 | 514 | D | 1 | 0 | J5IV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the clinical record for one (1) of six (6) sampled residents was accurate and complete related to the administration of antianxiety medication. Resident identifier: #52. Facility census: 78. Findings include: a) Resident #52 Review of the medication administration record (MAR) and narcotic administration record (NAR) found nursing staff did not accurately document the administration of [MEDICATION NAME] 0.5 mg. On 05/01/12, 05/07/12, and 05/12/12, [MEDICATION NAME] 0.5 mg was administered, but not documented on the MAR. The director of nursing agreed, at 12:30 p.m. on 05/21/12, nursing staff members did not accurately document the administration of [MEDICATION NAME] 0.5 mg for this resident. . | 2015-08-01 |
| 10004 | 10004 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2010-03-11 | 329 | D | 0 | 1 | XVZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the drug regimen for one (1) of eighteen (18) sampled residents was free of unnecessary drugs. Resident #78 was receiving [MEDICATION NAME] for an excessive duration, in the presence of adverse consequences, and without adequate monitoring. Medical record review revealed a gradual dose reduction (GDR), as required for drugs in this category, had not been attempted at least twice within one (1) year, in an effort to discontinue its use. Additionally, there was no evidence of monitoring and/or documentation to support the benefits of the medication outweigh the risks associated with its use either by the attending physician or the psychiatric consult. Facility census: 101. Findings include: a) Resident #78 Medical record review, on 03/10/10, disclosed this [AGE] year old female resident had medical [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. According to OBRA's "Unnecessary Drugs in the Elderly", [MEDICATION NAME] is a sedative drug with strong [MEDICATION NAME] properties with side effects of dehydration, causing dry mouth, confusion, decreased urine output, dry skin, poor skin turgor and constipation, all of which this resident already has and is being monitored for, in addition to problems of impaired nutrition, weight loss, and dehydration. Review of the resident's current comprehensive care plan found the [MEDICATION NAME] was given for behaviors of yelling, screaming, crying, tearfulness, increased anxiety, refusal of necessary hygiene, and refusal to take medications at times. Review of physician's progress notes and a review of the progress note from the psychiatric consult, dated 01/06/10, found no documentation to support the benefits of the medication outweigh the risks associated with its use either by the attending physician or the psychiatric Review of the pharmacist's recommendations to the physician revealed the pharmacist had … | 2015-07-01 |
| 10091 | 10091 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 329 | D | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the drug regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs. Resident #28 was ordered [MEDICATION NAME] 0.5 mg on 01/15/10 for Mild Mental [MEDICAL CONDITION] in the absence of adequate indications for it use. Facility census: 112. Findings include: a) Resident #28 Record review revealed Resident #28 was admitted to the facility on [DATE], and the hospital discharge summary for that date indicated the resident was receiving [MEDICATION NAME] 0.5 mg prior to admission to the facility. Copies of hospital records on the resident's medical record, when reviewed, contained no information explaining why the resident required this medication. The resident's 01/15/10 admission physician's orders [REDACTED]. Review of the physician's progress notes from 01/15/10 forward failed to find any documentation of the indications for use of the [MEDICATION NAME]. Review of the resident's 01/26/10 care plan found the resident was receiving [MEDICATION NAME] for "MR with behaviors" and "Behavioral symptoms drug is intended to treat: Resists care". This information was reviewed with the director of nursing on 03/04/10 at 4:00 p.m., and she agreed the indications for giving this resident [MEDICATION NAME] were inadequate. She reported having reviewed the medical record and finding no additional information concerning this matter. . | 2015-07-01 |
| 9916 | 9916 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-06-08 | 514 | D | 1 | 0 | D9VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the medical record for one (1) of six (6) sampled residents was accurately documented. Resident #202 experienced multiple loose watery stools associated with a [MEDICAL CONDITIONS] infection. The facility failed to record the number of loose stools experienced by the resident. Resident identifier: #202. Facility census: 123. Findings include: a) Resident #202 Review of the medical record found Resident #202 was diagnosed with [REDACTED]. The nursing notes documented loose, thin, liquid stools on 05/10/12, 05/11/12, 05/12/12, 05/13/ 12 and 05/14/12. The documentation did not include an accurate accounting of the number of loose watery stools experienced by the resident. An interview with the director of nursing (DON), Employee #121 on 05/07/12 at 2:00 p.m. confirmed that nursing staff members did not accurately document the number of loose watery stools the resident experienced on the above dates. . | 2015-08-01 |
| 10700 | 10700 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 428 | D | 1 | 0 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the pharmacist identified and reported irregularities found in the medication regimen of one (1) of forty-five (45) Stage II sample residents. One (1) resident had a drug prescribed without a supporting diagnosis, and this was not identified by the consultant pharmacist. Resident identifier: #159. Facility census: 105. Findings include: a) Resident #159 On 08/09/11 at approximately 10:25 a.m., medical record review for Resident #159 revealed she received the medication Mirapex 1 mg po (by mouth) twice a day everyday for Parkinson's disease since 08/18/10. Further medical record review found the resident did not have an active [DIAGNOSES REDACTED]. Interviews with Employee #27A (the director of nursing - DON) and Employee #28A (a registered nurse consultant) revealed no supporting [DIAGNOSES REDACTED]. Review of the resident's most recent medication regimen review by the consultant pharmacist, dated 07/13/11, found no irregularities were identified. . | 2014-12-01 |
| 9913 | 9913 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-06-08 | 157 | D | 1 | 0 | D9VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the treating physician was notified when nursing staff members were unable to administer ordered intravenous therapy for fluid replacement purposes. One (1) of six (6) sampled residents was affected. Resident identifier: #202. Facility census: 123. Findings include: a) Resident #202 Review of the medical record found the resident was admitted to the facility on [DATE] for treatment of [REDACTED]. The resident was determined to lack the capacity to make medical decisions by the treating physician on 04/25/12, with adult protective services (APS) appointed as the resident's health care surrogate. On 05/10/12, laboratory results were positive for a [MEDICAL CONDITIONS] infection. The resident was ordered and began receiving [MEDICATION NAME] 500 mg three (3) times a day (tid) on 05/10/12. The nursing notes documented loose, thin, liquid stools on 05/10/12, 05/11/12, 05/12/12, 05/13/ 12, and 05/14/12. treatment for [REDACTED]. On 05/14/12, the resident was visited by the nurse practitioner who documented the resident to be lethargic and hypotensive. The nurse practitioner ordered 2000 cc normal saline intravenous (IV) fluids on 05/14/12. The order, written at 10:20 a.m. on 05/14/12, specified a bolus of 1000 cc of normal saline for the first liter, then 85 cc/hr for the second liter of fluids. Review of the nursing notes found IV access was was obtained at 12:23 p.m. for administration of the first bolus liter of normal saline. Further review of the nursing notes found a note written at 2:07 a.m. 05/15/12, which documented, "Attempted IV access X 2 which was unsuccessful...". The medical record contained no documentation of what circumstances prompted nursing to again attempt IV access. A late entry note, by the nurse practitioner on 05/15/12, documented "nursing reports pulled out IV, received 900 ml of normal saline". The medical record contained no evidence the… | 2015-08-01 |
| 10692 | 10692 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 157 | D | 1 | 0 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to immediately notify an interested family member when one (1) of forty-five (45) Stage II sample residents, who was alert and oriented, experienced an acute change in condition resulting in transfer to a local hospital emergency department. Resident identifier: #162. Facility census: 105. Findings include: a) Resident #162 On 08/08/11 at approximately 1:00 p.m., medical record review for Resident #162 revealed he had the capacity to make his own medical decisions. The review also revealed two (2) nursing notes pertaining to an acute change in the resident's physical condition. - A nursing note, dated 07/04/11 at 12:15 p.m., stated: "Called (physician name) on his cell phone. Rec'd (received) order to send to ER (emergency room ) for eval (evaluation) 911 called. Res (resident) sent via stretcher with 2 attendants noted to have left side weakness and slight facial droop. Remains alert and responsive. 02 NC (nasal cannula) on with 02 sat 92-94. Ambulance personnel failed to take med (medical) records packet (transfer, md orders and d/c summary with them)." - A nursing note, dated 07/04/11 at 17:05 (5:05 p.m.), stated, "This nurse informed (resident's sister's name) that res. was transferred to (name of hospital) for eval (evaluation) at approx (approximately) 12:15 p.m. Res. sister approached this nurse to ask if res. (resident) had gone to ER. This nurse informed her 'yes.' Call placed to (name of hospital) ER. Res. has been admitted to (name of hospital) for [MEDICAL CONDITION] and [MEDICAL CONDITION] ischemia. Sister completely updated on status." On 08/08/11 at approximately 2:00 p.m., the director of nursing (DON - Employee #27A) reviewed the nursing notes in the medical record and reported her belief that the family had received notification of the resident's change in condition. She also felt that the resident's capacity status relieved the facility of any further… | 2014-12-01 |
| 11533 | 11533 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2010-09-28 | 441 | D | QQ4P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to maintain an infection control program designed to prevent the spread of infection within the resident environment to the greatest extent possible. One (1) of four (4) sampled residents with an open portal of entry (an indwelling urinary catheter) was cohorted in a room with a resident with a wound that cultured positive for an infectious organism. Resident identifier: #27. Facility census: 89. Findings include: a) Resident #27 Medical record review for Resident #27, conducted on 09/27/10 and 09/28/10, revealed Resident #27, who was being treated by a urologist, had an indwelling Foley urinary catheter inserted from 07/26/10 through 07/30/10. On 07/26/10, the physician ordered: "1. [MEDICATION NAME] plus 1 tablet po (by mouth) bid (twice a day) x 5 days dx (diagnosis) pain. 2. If pain continues may resume Tylenol #3 1 tablet po four times a day PRN (as needed). 3. Stop Keflex. 4. [MEDICATION NAME] mg 1 tablet po bid x 2 weeks. F/C (indwelling Foley urinary catheter) care q (every) shift until Friday 07/30/10." Review of the resident's nursing notes revealed the following entries: - On 07/26/10 - "F/C patent to leg ..." - On 07/27/10 - "F/C patent to leg drainage bag. Orange urine noted ..." - On 07/28/10 - "F/C patent to drainage on leg bag. Some leakage noticed but good flow ..." - On 07/30/10 - "Cath was removed yesterday R/T (related to) burning and leaking ..." During this time, Resident #27 shared a room with Resident #90, who was in contact isolation from 07/21/10 through 08/26/10. - b) Resident #90 Medical record review for Resident #90 revealed lab results, dated 07/14/10, showing positive growth of Methicillin-resistant Staphylococcus aureus (MRSA) in wounds on his right foot. On 07/21/10, Resident #90 was placed in contact isolation due to this MRSA infection, for which he was treated with several courses of antibiotics. A follow-up wound culture, dated 08/0… | 2014-01-01 | ||
| 10912 | 10912 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2011-07-28 | 514 | D | 1 | 0 | TF5T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to maintain clinical records on each resident in accordance with accepted standards of practice that were complete and accurately documented. The medical record of one (1) resident lacked sufficient documentation to chronicle an acute episode. In another resident's discharge summary, the physician's signature was not dated to identify when the summary was completed. A third resident's physician's orders [REDACTED]. Resident identifiers: #34, #51, and #37. Facility census: 57. Findings include: a) Resident #34 Review of Resident #34's medical record found she had developed a nose bleed the afternoon of 06/30/11. An INR (a test to assess the anticoagulation effect of [MEDICATION NAME]) was found to be high. She was sent to the hospital later that evening after injections of Vitamin K failed to stop the bleeding. - The nursing entries (typed as written) for this acute episode on 06/30/11 were: - 12:23 p.m. - "Resident refused to eat her lunch ,then wanted ice for Pepsi." - 3:30 p.m. - "Lab calls this nurse with critical PT/INR of 42.3/8.7" - 3:45 p.m. - "Doctor on call notified of PT/INR Receive new order Vitamin K PO (by mouth) 2.5 mg times one dose now." - 3:50 p.m. - "Dr. (Name) notified of by mouth Vitamin K availability. Receive order to discontinue [MEDICATION NAME] 5.5 mg. Dr. (Name) states 'Will call back.'" - 5:03 p.m. - "Dr. (Name) call this facility. Receives order Vitamin K 5 mg Intramuscular times one dose now. Re-check PT/INR in morning." - 5:10 p.m. - "Vitamin K 5 mg per doctor order administered at this time to resident's left ventro-gluteal area. Resident tloerated well." - 8:30 p.m. - "Dr. (Name) notified of slow results of earlier Vitamin K order. Receive new order Vitamin K 5 mg Intramuscular times one dose now and CBC in morning." - 8:35 p.m. - "Vitamin K 5 mg Intramuscular administered at this time per doctor's order to right ventro-gluteal area. Resi… | 2014-11-01 |
| 9891 | 9891 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-08-25 | 513 | D | 0 | 1 | MZQB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain in a timely manner and file on the medical record the results of diagnostic services performed on one (1) of fourteen (14) sampled residents. The results of diagnostic procedures performed to evaluate Resident #33's urinary tract were not obtained and filed on the resident's medical record until thirteen (13) days after the procedures were completed. Resident identifier: #33. Facility census: 140. Findings include: a) Resident #33 Medical record review, on 08/22/11, revealed this [AGE] year old male with [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder had an indwelling Foley urinary catheter in place for a long time. He also had experienced a history of urinary tract infections and [MEDICAL CONDITION]. Resident #33 had a history of [REDACTED]. Further medical record review revealed the resident, at a local hospital on [DATE], underwent a rigid cystourethroscopy (endoscopy of the urinary bladder via the urethra, carried out with a cystoscope). The resident also had a bilateral retrograde pyelography with interpretation (a procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney). These tests revealed no evidence of hydrouretero[DIAGNOSES REDACTED] (distension of the kidney and/or ureter caused by backward pressure on the kidney when the flow of urine is obstructed). (http://www.merckmanuals.com/home/kidney_and_urinary_tract_disorders/obstruction_of_the_urinary_tract/hydro[DIAGNOSES REDACTED].html#v 1) - When asked about the results of the above mentioned diagnostic procedures on 08/22/11 at 12:00 p.m., Employee #200 (a registered nurse) reported the facility had not yet received the report. She said she had this on a list of items she needed to get. On 08/23/11 at approximately 10:00 a.m., the facility obtained a copy of the diagnostic test results. - Review of the operative report for these two (2) procedur… | 2015-08-01 |
| 10782 | 10782 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2011-08-31 | 504 | D | 1 | 0 | ZR0U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain laboratory services in accordance with physician orders [REDACTED]. Resident identifier: #70. Facility census: 82. Findings include: a) Resident #70 Review of Resident #70's medical record, conducted on 08/30/11 and 08/31/11, revealed this [AGE] year old female had the following Diagnoses: [REDACTED]. Review of the resident's physician orders [REDACTED]." Review of the medical record found no evidence the UA and C&S were completed as ordered. On 08/31/11 at approximately 12:30 p.m., interview with the director of nursing (DON - Employee #102) confirmed the facility did not complete the UA and C&S. The DON stated the facility had approximately five (5) nurses who worked to try and get a urine specimen from the resident, but they had difficulty because of her incontinence. She went on to say they attempted to use the method of straight catheterization to obtain the urine sample, but this did not work either as they ran into difficulty and could not complete the procedure. On 08/31/11 at approximately 4:00 p.m., the DON informed this surveyor that the resident's physician knew the facility did not obtain the UA and C&S, but he did not order anything additional due to the order he had written for [MEDICATION NAME] (antibiotic) 500 mg. Subsequent review of the medical record found no evidence to reflect staff made the physician aware of their inability to obtain a urine specimen for the UA and C&S. | 2014-12-01 |
| 9900 | 9900 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-06-21 | 502 | D | 1 | 0 | MNCH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain laboratory services to meet the needs of one (1) of five (5) sampled residents. Resident identifier: #92. Facility census: 117. Findings include: a) Resident #92 Review of the medical record found Resident #92 was readmitted to the facility on [DATE] following an acute care stay. Review of the hospital discharge summary found the resident was to have a basic metabolic panel (BMP) in one (1) week. Review of the facility admission orders [REDACTED]. The medical record contained no evidence the facility had obtained this ordered laboratory service. An interview with the director of nursing (DON), Employee #10, on the afternoon of 06/21/12, confirmed the facility did not obtain the ordered laboratory test. . | 2015-08-01 |
| 10925 | 10925 | MCDOWELL NURSING AND REHABILITATION CENTER, LLC | 515162 | PO BOX 220 | GARY | WV | 24836 | 2011-07-08 | 502 | D | 1 | 0 | 34ZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain ordered laboratory services to meet the needs of one (1) of five (5) sampled residents. The facility failed to obtain an ordered Hgb A1c test for Resident #200 following a blood glucose result of 265 mg/dl (normal range 74 gm/dl to 106 gm/dl). Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 Record review revealed Resident #200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He received insulin injections of 30 units of [MEDICATION NAME]75/25 in the morning and 10 units of [MEDICATION NAME]in the evenings. Review of a complete blood count (CBC), ordered by the physician on 11/12/10, found the resident's glucose was 265mg/dl (with a normal range for this laboratory of 56 - 99 mg/dl). The nurse practitioner was notified of the report and ordered an Hgb A1c test. A nursing note, written on 11/13/10 at 7:26 a.m., documented the following: "Hgb A1c No lab pick up on Saturdays." Further review of the medical record found no evidence that the facility obtained this ordered test. On 12/06/10, the resident was found unresponsive and transported to an acute care facility. A blood test conducted upon admission found the resident's blood glucose was 886 mg/dl. He was diagnosed with [REDACTED]. | 2014-11-01 |
| 7746 | 7746 | CAMERON NURSING AND REHABILITATION CENTER | 515125 | ROUTE 4, BOX 20 | CAMERON | WV | 26033 | 2013-05-01 | 502 | D | 0 | 1 | H1U811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain physician ordered laboratory services for one (1) of nineteen (19) Stage 2 sample residents. Resident #50 did not receive a liver function test as ordered. resident identifier: #50. Facility Census: 44. Findings include: a) Resident #50 When reviewed on 04/24/13 at 3:30 p.m., this resident's medical record revealed a physician's orders [REDACTED]. The test was ordered due to the [DIAGNOSES REDACTED]. Further review of the medical record revealed the most recent liver function test available for this resident was dated 09/16/11. On 04/24/13 at: 4:05 p.m., the director of nursing stated she could not find evidence of a liver function test being completed after 09/16/11. She confirmed the resident had remained a resident at the facility since 09/16/11, and the liver function test should have been completed as ordered in July 2012. | 2017-02-01 |
| 10683 | 10683 | MILETREE CENTER | 515182 | 825 SUMMIT STREET | SPENCER | WV | 25276 | 2011-09-27 | 323 | G | 1 | 0 | 5CPP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide adequate supervision to promote resident safety, resulting in physical harm to one (1) of six (6) sampled residents. Resident #62 had a [DIAGNOSES REDACTED]. Her behaviors included wandering into other residents' rooms, hitting other residents and hitting staff, and engaging in verbally abusive behaviors towards others. On the evening of 06/23/11, she was observed holding a pillow over her roommate's face, after which she was transferred to local hospital on the evening of 06/23/11, and subsequently admitted to an inpatient psychiatric unit at a second hospital on [DATE]. When she returned to the nursing facility on 07/18/11, the facility's interdisciplinary team failed to review and revise her care plan with interventions such as increased staff supervision, to promote the safety of this resident and others because of her behaviors. On 07/25/11, Resident #62 wandered into the room of a male resident and hit him. The male resident hit her back, causing her to fall and sustain a fractured hip. Resident identifier: #62. Facility census: 61. Findings include: a) Resident #62 1. Record revealed Resident #62 was an [AGE] year old female who was originally admitted to this facility on 07/28/06. Her [DIAGNOSES REDACTED]. Further record review revealed, in December 2010, this resident exhibited signs and symptoms of psychosis and was transferred to a hospital's inpatient psychiatric unit for evaluation and treatment. According the hospital's discharge summary, her symptoms included the following (quoted as typed): "Restless behaviors like pacing and continually fingering certain object has increased. (Resident #62) cannot organize thoughts or following logical explanations. (Resident #62) becomes agitated and may hit, kick, bite, scream or grab. ... There are indications that (Resident #62) is hallucinating." Her treatment while on the inpatient unit consisted of med… | 2015-01-01 |
| 10910 | 10910 | GOLDEN LIVINGCENTER - GLASGOW | 515118 | PO BOX 350 | GLASGOW | WV | 25086 | 2011-07-13 | 323 | D | 1 | 0 | M5W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide an environment as free of accident hazards as possible for one (1) of six (6) sampled residents who sustained two (2) falls. The resident's drug regimen, which included the administration of an hypnotic medication every night for insomnia, was not reviewed to determine whether this medication was a possible causal or contributing factor to the falls. Resident identifier: #18. Facility census: 91. Findings include: a) Resident #18 Record review revealed Resident #18 was admitted to the facility's Alzheimer's Unit on 03/28/11, after an inpatient stay on a psychiatric unit. According to the medical record, this [AGE] year old male was receiving the hypnotic medication "Restoril 22.5 mg by mouth at bedtime everyday for insomnia." This medication was ordered while he was a patient on the psychiatric unit prior to his admission to this facility and was continued after his admission to the nursing facility. Record review revealed this resident had sustained two (2) falls during his stay at this facility. On 06/06/11 at 5:20 p.m., when he attempted to get up out of his bed, he slid to the floor. On 06/10/11 at 5:00 a.m., he was found on the floor; nursing documentation noted his gait was unsteady at that time and he was confused. The post-fall evaluation assessments and the care plan did not identify that this resident was receiving a large dose of Restoril, even after he experienced two (2) falls. There was no evidence that the facility considered the resident's falls risk was increased with this medication's use. A care plan (dated 06/06/11) was written after the resident was found on the floor following his first fall. There was no evidence his medications were reviewed or that the risks and benefits for the continued use of Restoril were discussed. The intervention in the care plan related to medication use simply stated: "Meds as ordered." The resident fell agai… | 2014-11-01 |
| 10724 | 10724 | GLEN WOOD PARK, INC. | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-08-24 | 281 | D | 1 | 0 | HTIL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide care to one (1) of (6) sampled residents in accordance with the physician's orders [REDACTED]. Resident #60 had orders to monitor her blood pressure and pulse prior to administering antihypertensive medications; a nurse failed to obtain and record the resident's blood pressure and pulse prior to administering these medications as ordered by the physician. The nurse also failed to record the resident's blood sugar level as indicated on the physician's orders [REDACTED].#60. Facility census: 59. Findings include: a) Resident #60 Review of the Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. No evidence could be found that Employee #70 followed the physician's orders [REDACTED]. Further review of the MAR found initials indicating a nurse obtained Resident #60's blood sugar at 8:00 p.m. on 07/29/11, but there was no record of the blood sugar level itself. Interview with the director of nursing, at 1:00 p.m. on 08/24/11, confirmed Employee #70 did not document a blood sugar, pulse, or blood pressure of Resident #60 for this date and time. . | 2014-12-01 |
| 10898 | 10898 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-01-28 | 412 | D | 0 | 1 | BY0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide dental services for one (1) of forty-one (41) Stage II sampled residents due to an information flow problem. The registered dietitian recommended Resident #148 receive a dental consult for loose-fitting dentures; this recommendation was not acted upon before being filed in the medical record. Resident identifier: 148. Facility census: 147. Findings include: a) Resident #147 Medical record review, on 01/27/10, revealed nutrition risk assessment dated [DATE], on which the registered dietitian recorded the need for a dental consult to evaluate loose-fitting dentures. Review of physician orders, physician progress notes [REDACTED]. In an interview on 01/27/10 at 2:30 p.m., the social service worker (Employee #92) reported the social services staff had not been informed of the need or request for a dental consult. In an interview on 01/27/10 at 3:30 p.m., the dietitian (Employee #172) related she was not aware whether the consult had occurred. In a subsequent interview on 01/28/10, Employee #92 confirmed this consult had not been completed, because the recommendation for the consult was not communicated to staff responsible for obtaining orders for and scheduling such consults. . | 2014-11-01 |
| 11008 | 11008 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-05-24 | 314 | D | 1 | 0 | BC7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide necessary treatment and services to promote healing of pressure sores for two (2) of nine (9) sampled residents. Resident #112, who had an alteration in the skin integrity of her left heel and whose physician ordered that her heels be elevated when in bed, was observed on multiple occasions with her heels in direct contact with the mattress. For Resident #6, the treatment for [REDACTED]. and left elbows. Facility census: 113. Findings include: a) Resident #112 Medical record review revealed Resident #112 was re-admitted to the facility on [DATE], with three (3) pressure ulcers to the coccyx and a non-pressure wound to the left heel. The wound on the left heel was documented as having an ecchymosed area measuring 2.5 cm x 1.5 cm. On 04/19/11, a physician's orders [REDACTED]." Observation, on 05/23/11 at 9:50 a.m., found Resident #112 lying in bed with her heels in direct contact with the mattress (not elevated as directed by the physician). Employee #43, a licensed practical nurse (LPN) who was passing medication on the resident's hallway, was advised of the situation and entered the resident's room. When asked if the resident's heels should be elevated, she replied, "I do not know. I do not have the treatment book." Employee #43 stated she would tell the treatment nurse. Observation, on 05/23/11 at 10:45 a.m., again found the resident lying in bed with her heels in direct contact with the mattress (not elevated as directed by the physician). Employee #78, who was the LPN treatment nurse, was alerted by the surveyor to observe the resident. Employee #78 entered the resident's room and placed a pillow under the resident's lower legs to elevate the heels. On 05/23/11 at approximately 3:30 p.m., the director of nursing (DON) was advised of the above findings. At that time, the DON observed Resident #112 in her room with the surveyor and found her again lying in b… | 2014-09-01 |
| 10011 | 10011 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 502 | D | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide or obtain laboratory services to meet the needs of one (1) of eleven (11) sampled residents. Resident identifier: #40. Facility census: 53. Findings include: a) Resident #40 Review of Resident #40's medical record found a physician's orders [REDACTED]. Further review found no evidence the resident had been provided with this laboratory service. A review of the resident's bowel history found staff had an opportunity to provide the serial test for blood in the resident's bowel movements on 02/01/10 during the 7:00 a.m. to 3:00 p.m. shift, on 02/02/10 on the 7:00 a.m. to 3:00 p.m. shift, and on the night and morning shifts on 02/04/10. An interview with the director of nursing (DON - Employee #96) confirmed the facility did not provide or obtain this ordered laboratory test. . | 2015-07-01 |
| 10010 | 10010 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 425 | D | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide pharmaceutical services to assure one (1) of eleven (11) residents received ordered medications in a timely manner. Resident identifier: #40. Facility census: 53. Findings include: a) Resident #40 Review of Resident #40's medical record found a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Documentation on the MAR indicated [REDACTED]. An interview with the director of nursing (DON - Employee #96), on 03/03/10 at 12:00 p.m., revealed the facility's back-up pharmacy closes at 5:00 p.m., and orders placed after 3:00 p.m. to their contracted pharmacy are not delivered until approximately 3:00 a.m. She also reported Doxycycline was not among the drugs kept in the emergency drug box. . | 2015-07-01 |
| 10464 | 10464 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2011-11-03 | 282 | D | 1 | 0 | 9Y2111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide services as outlined in the established care plans for two (2) of fourteen (14) sampled residents. The residents' care plans identified specific approaches direct care staff was to employ to address each identified problem, but these approaches were not consistently implemented. For Resident #85, a care plan meeting was held, and a special form was developed to document the times the staff offered to get the resident out of bed during each day and the amount of time the resident agreed to stay up. The form was not used daily, and the resident had never signed the form as agreed. For Resident #3, podiatry visits were not provided every sixty (60) days as specified in the care plan. Resident identifiers: #85 and #3. Facility census: 97. Findings include: a) Resident #85 Medical record review revealed a [AGE] year old male resident whose [DIAGNOSES REDACTED]. The attending physician had declared the resident to possess the capacity to understand and make his own medical decisions. Review of the interdisciplinary progress notes in the medical record found a "special care plan meeting held with ombudsman present" on 10/13/11. "Goals were set as a group for resident's future." During an interview with the social services director (Employee #107) on the afternoon of 11/01/11, she stated a meeting was held on 10/31/11 to plan for the resident's future. According to the social worker, Resident #85 has alleged that he does not get out of bed daily because staff fails to get him up. A form was developed by the social worker, which required nursing staff to document the times, dates, and the length of time the resident was out of bed daily. If the resident refused to get out of bed, this was also to be documented on the form. The resident was to sign the form daily to verify the documentation of the staff. The interdisciplinary team was to meet again in one (1) month to … | 2015-03-01 |
| 10164 | 10164 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-02-01 | 314 | G | 1 | 0 | RZ6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide the necessary care and services for one (1) of forty-nine (49) Stage II sample residents to prevent an avoidable pressure ulcer [MEDICAL CONDITION]. This failure resulted in a finding of harm to the resident. The resident developed a stage I pressure ulcer on the right heel. Ortho boots were applied to relieve pressure. Weekly skin audits were ordered by the physician, but were not done. The pressure ulcer developed into an unstageable ulcer with necrotic eschar and infection, which required hospitalization for debridement and a course of IV antibiotic therapy. The unstageable ulcer was discovered during an outside cardiac consult. When discovered, the resident was taken directly to the hospital emergency room by his family. Resident identifier: # 68. Facility census: 82. Findings include: a) Resident # 68 During medical record review, a physician's orders [REDACTED]. The order was, "D/C (discontinue) all previous treatment to right heel and cleanse right heel with NSS (normal saline solution) pat dry. Apply saf-gel cover with non-adherent pad. Wrap with Kling wrap and change every day PRN (as needed)." This discovery prompted further investigation that revealed the resident had developed an avoidable pressure ulcer. Medical record review revealed a note, written by the midnight nurse on 12/08/11. The note stated, "Assessed resident finding unstageable pressure ulcer to right medial heel measuring 7.6 cm X 0.0 cm. Ulcer covered with gray soft, leathery, adherent tissue. Scant amount clear drainage with no odor observed. Also noted to left medial heel stage II closed blister measuring 2.1 cm x 1.9 cm Stage II closed blister to left arch of foot measuring 1.4 cm. x 2.1 cm. Treatment in place to apply [MEDICATION NAME] bilaterally every shift, also had nutritional supplements to aid in wound healing...." Review of physical therapy notes, dated 12/08/11, revealed… | 2015-06-01 |
| 10335 | 10335 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2011-03-18 | 205 | D | 1 | 1 | I28Y12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide to the resident (and a family member or legal representative) a written notice which specified the duration of the facility's bed-hold policy when one (1) of sixteen (16) sample residents was transferred to the hospital due to urgent medical needs. Resident identifier: #102. Facility census: 116. Findings include: a) Resident #102 Medical record review, on 03/16/11, revealed this resident was admitted to the facility on [DATE]. On 03/14/11, the resident was transferred to the hospital due to an acute change in condition. The medical record contained no evidence the resident was provided a written notice which specified the duration of the facility's bed-hold policy. At 1:45 p.m. on 03/16/11, an interview was conducted with the director of nursing (DON - Employee #45). When asked for evidence the required information was provided to the resident and a family member or legal representative, the DON stated the information was included in a packet of information which the facility sent to the hospital with Emergency Medical Services (EMS) upon transfer. Further interview revealed the facility was unable to provide evidence this information was sent with the resident; and there was no evidence a family member or legal representative was also provided the written bed-hold policy when Resident #102 was transferred to the hospital. In addition, the facility had no means of assuring the resident and a family member or legal representative got this information, since it was included in a packet of medical information intended for the hospital. On 03/17/11 at 9:00 a.m., a discussion was held with the facility's administrator (ADM - Employee #10), regarding the provision of a written bed-hold policy to the resident and a family member or legal representative upon transfer to the hospital. At that time, the ADM confirmed the facility had not been providing the information… | 2015-05-01 |
| 9957 | 9957 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-05-25 | 225 | D | 1 | 0 | 68YL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to report and investigate an allegation of neglect for one (1) of fourteen (14) sample residents. A resident was transported to the hospital, where it was found his catheter was draining foul smelling purulent/green fluid. The resident also had a stage II pressure area on his penis from the catheter tubing. Due to the resident's condition, the hospital alleged neglect and reported it to Adult Protective Services (APS) and the facility. The facility did not report the allegation to the State survey agency or the ombudsman as required by State law. In addition, the facility did not investigate the allegation of neglect. Resident identifier: #55. Facility census: 59. Findings include: a) Resident # 55 Medical record review revealed this resident was admitted to the facility on [DATE]. He was sent to the hospital for treatment of [REDACTED]. Upon return from the hospital, he had pressure ulcers on his buttocks. According to the medical record, an indwelling Foley catheter was inserted on 02/10/12 to help keep the pressure ulcers dry. On 02/24/12, the resident was transported to Hospital #1, where he was diagnosed with [REDACTED]. The resident was again transported to Hospital #1 on 04/19/12. On the same day, he was transported to Hospital #2 due to his full code status. The medical record from Hospital #2 was reviewed. The history and physical from Hospital #2 noted the resident's [DIAGNOSES REDACTED]. The resident also had an indwelling Foley catheter which was draining foul smelling purulent/green fluid. In addition, he was admitted with a stage II pressure ulcer on his penis, which appeared to be from the catheter. Hospital #2's nursing note described the Foley catheter was removed and the resident "spewed foul-smelling pus and urine." A new catheter was placed and drained 900 ml of purulent green urine. An interview was conducted with the Regional CQI Director (Employee… | 2015-08-01 |
| 10977 | 10977 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2011-06-30 | 280 | D | 1 | 0 | K8MG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to review and revise the care plan for one (1) of fourteen (14) residents (#119) who exhibited aggressive behaviors toward her roommate (#95). Resident identifiers: #95 and #119. Facility census: 116. Findings include: a) Resident #95 1. Medical record review for Resident #95 revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her Medicare 30-day minimum data set assessment (MDS) with an assessment reference date (ARD) of 05/03/11, her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. She was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene, and bathing, and she required extensive assistive from staff with transferring, walking, and eating. -- 2. Further review of Resident #95's medical record revealed the following nursing notes (quoted as written): - On 05/31/11 at 2:00 p.m. - "Pt's (patient's) family member came to desk and stated 'my mom told me that her roommate woke her up with her hands around his throat yelling - 'If you don't quit sleeping /c (with) my husband, I will kill you'. Daughter stated 'Mom is very afraid of her roommate and asked for a room change. Asked for a grievance form and assisted to the social services office. Explained the situation to the social service director and commented about the dangers of the two residents in the same room. Will continue to monitor." - On 05/31/11 at 3:15 p.m. - "Roommates continue to argue. Assisted resident to nurses desk to ensure safety." - On 05/31/11 at 5:20 p.m. - "Resident was sitting in recliner and 'dodged' a empty coffee cup that the roommate had thrown. Continue to have conflict and social services notified of continuing conflict." - On 06/02/11 at 7:00 a.m. - "Called to … | 2014-10-01 |
| 9853 | 9853 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 280 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan for one (1) of thirty-six (36) Stage 2 sample residents who experienced a decline in condition. The care plan in use did not reflect the resident's current status. Resident identifier: Resident #110. Facility census: 92. Findings include: a) Resident #110 Resident #110 had a [DIAGNOSES REDACTED]. Medical record review, on 04/04/13, found nursing notes, dated 03/10/13 and 03/11/13, that described conversations between nursing and the representative of Resident #110 "regarding resident condition and possible hospice consult." At that time, it was determined the resident would have a "hospice referral for palliative care and pain management if need be." A social services note, dated 03/26/13, included ". . . he has had a significant emotional change. Resident has also had physical decline and is now palliative care." On 04/02/13, another social services note stated "Resident needs much encouragement he is depressed and receiving palliative care." Review of current care plan found no indication of any decline in the resident's condition, the provision of palliative care services, or that he was a potential hospice candidate. There was nothing in the care plan addressing a decline in functioning. In fact, one goal regarding physical functioning was "I will improve my current level of physical functioning." This concern was discussed with the MDS Coordinator on 04/09/13 at 12:00 p.m. She was unable to provide information the care plan was revised after the resident's change in condition. . | 2015-08-01 |
| 9857 | 9857 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2015-01-08 | 520 | D | 1 | 0 | YJ9E12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to utilize its Quality Assessment and Assurance (QAA) committee effectively regarding resident refusals of medication. The facility failed to notify the physician of the refusals and failed to provide education to the resident as to the potential consequences of the refusals. Resident identifier: #27. Facility census: 84. Findings include: a) Resident #27 Medical record review on 01/08/15 at 12:00 p.m. revealed this [AGE] year old resident was admitted to the facility in September 2014. His [DIAGNOSES REDACTED]. He was prescribed a diuretic, [MEDICATION NAME], 80 (eighty) milligrams twice daily related to [MEDICAL CONDITION]. Review of the nurse progress notes for December 2014 and January 2015 revealed numerous occasions where he had refused the morning dose of [MEDICATION NAME]. There was no evidence nursing staff had notified the physician of these multiple refusals. There was no evidence of nursing education with the resident related to the consequences of continued [MEDICATION NAME] refusals. There was no evidence of communication with the resident to try and find out the reasons for the refusals. Review of the Medication Administration Record [REDACTED]. Review of the MAR for January 2015 revealed he refused his morning dose of [MEDICATION NAME] on 01/03/15, 01/04/15, 01/05/15, 01/06/15, 01/07/15, and 01/08/15. During an interview with the director of nursing (DON) on 01/08/15 at 1:15 p.m., she was asked if there was some evidence the physician had been notified of the resident's refusals of the morning doses of [MEDICATION NAME]. The DON said she would check as she was not very familiar with this resident. On 01/08/15 at 2:25 p.m., in another interview with the DON, she said she contacted the physician that day about the [MEDICATION NAME]. She provided a copy of a nurse progress note dated 01/08/15 with the effective time of 1:41 p.m. and created at 1:46 p.m. The… | 2015-08-01 |
| 9948 | 9948 | WELLSBURG CENTER LLC | 515123 | 70 VALLEY HAVEN DR | WELLSBURG | WV | 26070 | 2010-07-08 | 279 | E | 0 | 1 | GJYW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for four (4) of twenty-three (23) Stage II sample residents, to develop a comprehensive plan of care for each resident exhibiting behavioral symptoms for which he/she is receiving [MEDICAL CONDITION] medication, to include non-pharmacologic interventions to address these behaviors. Resident identifiers: #8, #28, #4, and #58. Facility census: 49. Findings include: a) Resident #8 Medical record review, on 06/30/10, revealed Resident #8, a [AGE] year old female admitted to the facility on [DATE], exhibited behaviors including tearfulness, verbal abuse, and repetitive health complaints, and the physician ordered the antipsychotic medication [MEDICATION NAME] 25 mg by mouth daily for [MEDICAL CONDITION]. Review of the resident's behavioral monitoring tracking record found the behavioral symptoms occurred infrequently, with only two (2) episodes in the months of April and May 2010. On 05/16/10, she was verbally abusive, and on 04/26/10, she was physically abusive; documentation indicated, in both instances, the behaviors were easily altered with one-on-one (1:1) staff interventions. When interviewed on 07/01/10 at 9:23 a.m., a nurse (Employee #62) related that it was unusual for Resident #8 to have behaviors, and she had not personally witnessed the resident exhibiting any of these behaviors. When interviewed on 07/01/10 at 9:35 a.m., another nurse (Employee #48) reported Resident #8's behaviors occurred infrequently; the last time she exhibited any behaviors was on 06/24/10 and, prior to that, it was in May. Employee #48 also identified that, when the resident exhibited behaviors in June, she was successfully redirected with 1:1 staff interaction. Review of the resident's care plan found no plan had been developed to ensure non-pharmacologic interventions (such as 1:1 staff intervention) were attempted in an effort to decrease the episodes of behaviors. -- b) Resident #28 M… | 2015-08-01 |
| 9912 | 9912 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2010-08-05 | 325 | D | 0 | 1 | 2XEX12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of fifteen (15) sampled residents, to ensure the resident received appropriate treatment and services to maintain acceptable parameters of nutritional status, by failing to ensure all direct care staff was aware of interventions identified by the rehabilitative therapy staff to reduce distractions during meal times and promote good oral intake. Resident identifier: #3. Facility census: 54. Findings include: a) Resident #3 1. Medical record review, on 08/04/10, revealed Resident #3 was admitted to the facility on [DATE]. On 10/28/08, the facility first identified she was at risk for decreased nutritional intake. On 06/10/10, she exhibited swallowing difficulties; the speech-language pathologist (SLP) assessed her and identified she needed a mechanical soft diet with ground meats. Resident #3 began receiving speech therapy (ST) and occupational therapy (OT) to address her decreased nutritional intake and promote self-feeding. Review of Resident #3's weight records revealed she weighed 194# on 05/19/10, weighed 188# on 06/09/10, and weighed 186# on 07/12/10. This represented an 8# weight loss in two (2) months. - 2. Review of the OT progress notes found the following entries: On 06/15/10 - "Pt (patient) seen for lunch meal, removed distracting items like butter knife and food ticket and pushed resident closer to table. Pt also sitting at same table but on opposite side away from distractions of dining room." On 06/16/10 - "Pt seen for lunch meal, provided a bright red place mat to define eating space, removed distracting items." On 06/17/10 - "Pt seen for breakfast meal, removed distracting items and cued patient to initiate meal (sic) pt complies. Discussed / educated present CNA (certified nursing assistant) staff on approaching patient, cueing patient and items to remove. Inservice completed to kitchen staff (servers, etc.) regarding patient (approaching pa… | 2015-08-01 |
| 9795 | 9795 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2010-06-01 | 325 | D | 0 | 1 | 2XEX12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of fifteen (15) sampled residents, to ensure the resident received appropriate treatment and services to maintain acceptable parameters of nutritional status, by failing to ensure all direct care staff was aware of interventions identified by the rehabilitative therapy staff to reduce distractions during meal times and promote good oral intake. Resident identifier: #3. Facility census: 54. Findings include: a) Resident #3 1. Medical record review, on 08/04/10, revealed Resident #3 was admitted to the facility on [DATE]. On 10/28/08, the facility first identified she was at risk for decreased nutritional intake. On 06/10/10, she exhibited swallowing difficulties; the speech-language pathologist (SLP) assessed her and identified she needed a mechanical soft diet with ground meats. Resident #3 began receiving speech therapy (ST) and occupational therapy (OT) to address her decreased nutritional intake and promote self-feeding. Review of Resident #3's weight records revealed she weighed 194# on 05/19/10, weighed 188# on 06/09/10, and weighed 186# on 07/12/10. This represented an 8# weight loss in two (2) months. - 2. Review of the OT progress notes found the following entries: On 06/15/10 - Pt (patient) seen for lunch meal, removed distracting items like butter knife and food ticket and pushed resident closer to table. Pt also sitting at same table but on opposite side away from distractions of dining room. On 06/16/10 - Pt seen for lunch meal, provided a bright red place mat to define eating space, removed distracting items. On 06/17/10 - Pt seen for breakfast meal, removed distracting items and cued patient to initiate meal (sic) pt complies. Discussed / educated present CNA (certified nursing assistant) staff on approaching patient, cueing patient and items to remove. Inservice completed to kitchen staff (servers, etc.) regarding patient (approaching patient… | 2015-09-01 |
| 10394 | 10394 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2011-12-06 | 279 | D | 1 | 0 | 78UH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of four (4) sample residents, to develop a care plan which included specific target behaviors and interventions, to observe and report, for a resident who was ordered Risperdone as needed (PRN) for sleep. Additionally, the care plan did not include non-pharmacological interventions to attempt prior to the use of the PRN Risperdone. Resident identifier: #9 Facility census: 25 Findings included: a) Resident #9 Medical record review, on 12/05/11, revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a physician's orders [REDACTED]. The order further noted the dose type was maintenance with an indefinite stop date. Review of the resident's care plan, dated 11/22/11, revealed a problem statement of "Potential for drug related [MEDICAL CONDITION] r/t (related to) use of antipsychotic medication, [MEDICATION NAME]." The goal for this problem stated "Will not exhibit side effects resulting from antipsychotic medication use. " Interventions for the problem included the following: - Administer medications as ordered. -Vital signs every shift or as indicated. -Report changes in mood and behavior. Interview with the director of nursing (DON), Employee #59, on 12/06/11 at 10:00 a.m., revealed the behavior (noted in the care plan) the resident exhibited was yelling out. She further explained the physician felt the sleep disturbance and behavior (yelling out) were related. When asked if the staff attempted non-pharmacological interventions such as redirection, offering food or drink, toileting, and/or assessing for pain, before giving the Risperdone, Employee #59 had no response. Review of the resident's mood and behavior documents, from 11/14/11 through 12/05/11, revealed "repeated questions and repeated verbalizations" at various times during a twenty-four (24) hour period. Another facility flow she… | 2015-04-01 |
| 11202 | 11202 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26505 | 2010-05-19 | 323 | G | 1 | 0 | 7YYR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of sixteen (16) sampled residents, to provide adequate supervision and/or assistive devices to prevent an accident with injury. Resident #6 had a [DIAGNOSES REDACTED]. A physical therapy evaluation identified her as being at risk for falling, and staff was aware of her tendency to lean forward in her wheelchair. The only interventions implemented to promote her safety related to falling was staff encouraging and reminding her to sit back in her wheelchair, directives which she was not able to remember and consistently perform on her own due to her impaired cognition. On the afternoon of 04/25/10, Resident #6 fell face first from her wheelchair and sustained a fractured nose. Resident identifiers: #6. Facility census: 61. Findings include: a) Resident #6 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE], for rehabilitation for debility, [DIAGNOSES REDACTED] (LBD), and resolved pneumonia and urinary tract infection. Other [DIAGNOSES REDACTED]. 2. According to information from the Alzheimer's Association (found via the Internet at ): "Dementia with Lewy bodies is characterized by abnormal deposits of a protein called alpha-synuclein that form inside the brain's nerve cells. ... "Symptoms of dementia with Lewy bodies (include) - Memory problems, poor judgment, confusion and other cognitive symptoms that overlap with Alzheimer's disease. - Excessive daytime drowsiness. - Visual hallucinations. - Cognitive symptoms and level of alertness may get better or worse (fluctuate) during the day or from one day to another. - Movement symptoms, including stiffness, shuffling walk, shakiness, lack of facial expression, and problems with balance and falls. ..." 3. Review of the resident's admission care plan, dated 04/21/10, noted the resident was exhibiting symptoms of decline in her cognitive function related to the LBD. Interventions we… | 2014-07-01 |
| 10770 | 10770 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2010-04-22 | 329 | D | 0 | 1 | UDOR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of thirty-seven (37) Stage II sample residents, to ensure the resident's medication regimen was free from unnecessary drugs given without adequate indications for use. Resident #81 was seeing a consultant psychiatrist on an outpatient basis every two (2) months; per family request, this consultant physician was the only person permitted to make changes to her psychoactive medications. There was no documentation in the resident's medical record by the consultant physician of the clinical rationale for continued use of antianxiety and antipsychotic medications. Resident identifiers: #81. Facility census: 94. Findings include: a) Resident #81 Medical record review, on 04/20/10, revealed Resident #81 received [MEDICATION NAME] 0.5 mg by mouth every six (6) hours as needed for anxiety, [MEDICATION NAME] 2.5 mg two (2) times a day an 8:00 a.m. and 2:00 p.m. due to behavioral disturbances, and [MEDICATION NAME] 5 mg by mouth every night for behavioral disturbances. According to the medical record, her behaviors were stable for the past year. Additional information in the medical record revealed only the consultant physician was permitted to make any changes in the resident's medications. No information could be found in the medical record concerning any consultations this resident had with this physician. In an interview on 04/10/10 at 2:36 p.m., a licensed practical nurse (LPN - Employee #79) identified that, a year ago, Resident #81 had some serious problem behaviors. The family now comes in every two (2) months and takes her to their own physician; if changes are needed in her medications, he makes them. Otherwise, this consultant physician does not make any documentation in the medical record, nor does he review the resident's overall medical record. Employee #79 also reported that, for about the past year, Resident #81's behaviors have been stable. In an inte… | 2014-12-01 |
| 10851 | 10851 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2010-02-11 | 309 | G | 0 | 1 | ZHEQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed, for one (1) of thirty-two (32) Stage II sampled residents, to ensure nursing staff conducted a thorough assessment of a resident immediately following a fall. Staff then ambulated the resident, resulting in reports of pain. Staff reassessed her by doing "pelvic rocks", resulting in increased reports of pain (actual harm). Resident identifiers: #21. Facility census: 95. Findings include: a) Resident #21 Medical record review, on 02/09/10, disclosed a document titled Hopemont Hospital Resident Incident / Accident Report dated 01/21/10 at 2:25 a.m., which contained information related to a fall sustained by Resident #21. Entries on the report stated: - "Incident (describe what happened): Unknown cause of fall, health service worker (HSW) responded to resident yelling." - "Resident response / reactions and consequences (included protocol): Assessment of resident while on floor. Reassessed upon c/o (complaint) hurting to walk, then reassessed in bed. Resident was cooperative with each assessment." Review of the nursing progress notes, dated 01/21/10, revealed the following entry: "Did an assessment on resident at that times no apparent injuries. Resident was able to stand with 2 person assist. Began to ambulate, at that time resident began stating that it hurts and she could not do it (walk to chair). We stood her at nurses station and did a more thorough assessment. No bruises, redness or enema noted at that time. Resident continued to favor her left side. We placed her in chair and took her to room. At that time (staff member's name) began assessing her by doing pelvic rocks and check external rotation and length of loere (sic) limb. During assessment resident began to c/o (complaint) more pain and even upon subject change during communication once area was pressed the resident immediately responded by stating stop, that hurts..." During an interview on 02/11/10 at 2:45 p… | 2014-12-01 |
| 9168 | 9168 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-01-01 | 279 | D | 1 | 0 | 8XAM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's interdisciplinary team failed to develop a comprehensive care plan to address the care needs and to describe the services needed for one (1) of five (5) sample residents regarding accidents/falls. There was no care plan for fall prevention for this resident who had a history of [REDACTED].#111. Facility census: 110 Findings include: a) Resident #111 Review of Resident #111's medical record revealed this resident was admitted to the facility on [DATE]. According to the hospital discharge summary provided on admission, this resident had generalized weakness and a documented fall which occurred during her hospitalization . Facility admission orders [REDACTED]. A fall risk assessment, completed by the facility, on 09/01/12, noted the resident was at risk for falls. According to nursing notes and an incident report, dated 09/06/12 at 9:30 p.m., Resident #111 was sitting up on the side of the bed. Staff heard her fall. Upon entering the resident's room, she was found lying on her back. She had a bruise on her left forehead, and her left upper and lower eyelids were [MEDICAL CONDITION]. A deep skin tear was noted on her left elbow and left forearm. The resident stated she hit her head when she fell . She was transferred to the hospital for evaluation due to the deep laceration on her left elbow/forearm and possible head injury. The resident returned to the facility on [DATE] a 1:20 a.m. The hospital had been unable to suture the laceration on the left elbow/forearm. Review of the resident's care plan revealed no interim or immediate care plan regarding the resident's risk for falls at the time of the residents's fall on 09/06/12. The information was available in the hospital discharge summary provided on admission on 08/31/12. In addition, the facility completed a fall risk assessment, on 09/01/12, and noted the resident was at risk for falls. On 01/01/13 at 10:00 a.m., Employee #1… | 2016-01-01 |
| 9812 | 9812 | CAMDEN CLARK MEM HOSP | 515145 | 800 GARFIELD AVENUE | PARKERSBURG | WV | 26102 | 2014-02-06 | 279 | D | 0 | 1 | MCG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's interdisciplinary team failed to develop a comprehensive care plan to address the care needs of a resident taking the medication [MEDICATION NAME], an anticoagulant. The care plan did not identify what measures were to be implemented to prevent and monitor for complications. This was evident for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #178. Facility census: 17. Findings include: a) Resident #178 A medical record review, on 02/05/14 at 10:55 a.m., revealed Resident #178 was receiving the medication [MEDICATION NAME]. The resident's care plan did not include any interventions for a resident receiving an anticoagulant. In an interview with Employee #1, a registered nurse and clinical nurse manager, on 02/05/14 at 11:05 a.m., she verified there was not a care plan for the anticoagulant. She stated that she had implemented a care plan for the resident after this was brought to her attention. . | 2015-09-01 |
| 11516 | 11516 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 501 | E | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's medical director failed to assume responsibility for the coordination of facility-wide medical care. There was no evidence of ongoing collaboration by the medical director with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct continuing non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care. Additionally, the medical director failed to coordinate medical care by not assuring Resident #143 received timely physician visits, and failed to assume the care of Resident #152 when nursing staff contacted him for medication for the resident, instructing staff to wait until Monday and contact the resident's treating physician to obtain a prescription to be faxed to the pharmacy. These practices affected two (2) of ten (10) sample residents during the current survey and had the potential to result in more than minimal harm to more than an isolated number of facility residents. Resident identifiers: #152 and #143. Facility census: 142. Findings include: a) The facility has had continued non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of quality of care (F309) during the last three (3) survey events at the facility, beginning with a survey event that concluded on 09/01/10, resulting in findings of deficiencies in quality of care at a level of harm. There was no evidence of ongoing collaboration with facility personnel to help develop, implement, and evaluate resident care policies and procedures to correct this continuing non-compliance. (See also citation at F309.) - b) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending p… | 2014-01-01 | ||
| 11425 | 11425 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 520 | E | U2Q612 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's quality assessment and assurance committee failed to identify quality deficiencies of which it was (or should have been) aware and develop and implement plans of action to correct these quality deficiencies. This resulted in the facility's continuing non-compliance with the Medicare / Medicaid conditions of participation. During the current survey from 01/03/11 through 01/07/11, the facility failed to correct deficient practices cited during previous survey events that concluded on 09/01/01 and 11/02/10, with respect to the following regulatory requirements: Comprehensive Care Plans (F279), Quality of Care (F309), and Pharmaceutical Services (F425), resulting in repeat deficiencies in these areas. These deficient practices affected three (3) of ten (10) sampled residents and presented the potential for more than minimal harm to more than an isolated number of residents at the facility. Resident identifiers: #150, #151, and #152. Facility census: 142. Findings include: a) Quality of Care 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Quality of Care (F309) resulting in findings of deficiencies at a level of actual harm to an isolated number of residents during two (2) previous survey events at the facility, which concluded on 09/01/10 and 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. 2. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to… | 2014-03-01 | ||
| 10254 | 10254 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-09-26 | 272 | D | 0 | 1 | FJI611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the resident's comprehensive did not accurately reflect the current health status / condition for one (1) of thirty-one (31) residents sampled in stage II of the QIS (Quality indicator survey). Resident identifier: #12. Facility census: 109. Findings include: a) Resident #12 Review of the medical record found the resident was admitted to the facility on [DATE], and was receiving [MEDICATION NAME] 100 mg daily and [MEDICATION NAME] 17 gram powder daily for a [DIAGNOSES REDACTED]. Further review disclosed a facility form entitled, "The Resident Functional Performance Record." This form was completed daily by the nursing assistants (NA). The form indicated the resident did not have a bowel movement from the date of admission, on 07/20/12, until 07/28/12. The Resident's minimum data set (MDS) with an assessment reference date (ARD) of 07/27/12, found section (H), bowel patterns, noted no constipation was present. No bowel movements were recorded by NAs from 07/20/12 through 07/27/12, and the Resident was receiving two (2) medications for a [DIAGNOSES REDACTED]. At 9:30 a.m. on 09/26/12, Employee #119, a registered nurse and regional director of clinical services, was interviewed and made aware of the documentation on the MDS. No further information was provided by the facility. . | 2015-05-01 |
| 9877 | 9877 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-07-26 | 514 | D | 1 | 0 | 2QL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, abuse/neglect reportable allegation review, and staff interview, the facility failed to ensure one (1) of nine (9) residents had a medical record that was maintained in accordance with accepted professional standards and practices which includes the records be complete and accurately documented. Resident identifier: #116. Facility census: 114. Findings include: a) Resident #116 On 07/24/12 at 12:00 p.m., the reportable allegations of abuse/neglect review revealed an allegation involving Resident #116. The resident had alleged she did not receive her pain medication ([MEDICATION NAME] 10/325 mg) on the night of 07/08/12. The medical record review revealed the physician had ordered the pain medication every four (4) hours as needed. The facility had contacted the physician and pharmacy on 07/08/12 and a new prescription of the medication arrived on the morning of 07/09/12. The narcotics sign out sheet revealed the facility did have thirty (30) tablets of [MEDICATION NAME] 10/325 mg at 8:00 a.m. on 07/09/12. The resident received a dose at that time On 07/24/12 at 3:00 p.m., the social worker (Employee #18) stated she investigate this allegation of neglect and had found the allegation unsubstantiated. Her investigation included a review of the resident's Medication Administration Record [REDACTED] On 07/24/12 at 4:00 p.m., Employee #65 (registered nurse) stated she came on duty at 11:00 p.m. and at that time Resident #116 had asked about her pain medication. The resident had received a dose of [MEDICATION NAME] 10/325 mg at 8:00 p.m. Employee #65 said she explained to the resident the situation involving the need to get a new prescription of [MEDICATION NAME]. She told the resident the pharmacy would deliver the new prescription on the morning of 07/09/12. Employee #65 said she informed the resident she could contact the physician and ask for an alternate pain medication. The resident declined. According to the … | 2015-08-01 |
| 9875 | 9875 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-12-01 | 329 | D | 0 | 1 | ENOI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, and staff interview, the facility failed to provide justification for the use of as needed (PRN) [MEDICATION NAME], a sedating drug, for one (1) of thirty-seven (37) sample residents. Resident #78 had a physician's orders [REDACTED]." Review of the Medication Administration Record [REDACTED]. Additionally, there was no evidence that non-pharmacological interventions had been attempted to control behaviors prior to giving [MEDICATION NAME]. This made the use of [MEDICATION NAME] an unnecessary drug. Resident identifier: # 78. Facility census: 85. Findings include: a) Resident #78 During the medical record review, it was discovered the physician had written an order, on 09/12/11 at 3:30 p.m., for [MEDICATION NAME] 0.5mg. one(1) tablet by mouth every evening for "severe agitation only." Review of physician progress notes [REDACTED]. During a review of nursing notes, dated 09/12/11 at 7:30 p.m, documentation revealed "Resident very confused calling at staff and even tried to hit staff, [MEDICATION NAME] 0.5mg given po (by mouth) @ (symbol for at) this time". There was no documentation indicating non-pharmacological interventions had been attempted prior to giving the [MEDICATION NAME]. Further review of the MAR indicated [REDACTED]. During a review of nursing notes it was found there had been no documentation about the resident's behaviors indicating the need for [MEDICATION NAME]. Further review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. There was no documentation which indicated the resident's behaviors which necessitated theuse of [MEDICATION NAME]. During an interview with the director of nursing (Employee # 54), on 12/01/11 at 9:20 a.m., it was agreed the nursing documentation failed to describe behaviors, and what behaviors should be considered severe. It was also agreed there was no evidence non-pharmacological interventions had been attempted before the [MEDICATION NA… | 2015-08-01 |
| 9979 | 9979 | SPRINGFIELD CENTER | 515188 | ROUTE 1 BOX 101-A | LINDSIDE | WV | 24951 | 2012-06-14 | 280 | D | 1 | 0 | 18U511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, care plan review, and staff interview, the facility failed to ensure the care plan was revised to reflect the resident's status and level of care for two (2) of five (5) residents reviewed. The facility had knowledge of changes in the plan of care for Resident #54 and Resident #25; however, the care plan did not reflect these changes. Resident identifiers: #54 and #25. Facility census: 52. Findings include: a) Resident #54 On 06/13/12, at approximately 10:00 a.m., medical record review for Resident #54 revealed a nursing note dated 05/05/12 at 11:30 a.m. The note stated, "BP (blood pressure) - 145/81 p (pulse) - 87 R (respiration) - 10 T (temperature) 97.3 Res. (resident) alert 02 (oxygen) sat (saturation) 94 % on O2 via nc (nasal cannula). Resp (respiration) shallow, non-labored. Res slid out of Geri-chair onto buttock; she did not hit her head. No apparent injury noted." The care plan review revealed the facility had care planned the resident's risk for falls. Resident #54 was at risk for falls due to impaired mobility, cognitive loss, [MEDICAL CONDITION] medication use, and intermittent confusion. This facility initiated care planning this problem on 04/11/12. The goal for the resident was for the resident to be free of serious injury related to falls as evidenced by no fracture, or no cerebral bleed. The interventions included "Assess cause, pattern of previous falls and act upon resolvable factors. Encourage and remind (Resident #54) to request assistance with needed transfers. PT/OT (physical/occupational therapy) consult as indicated. Keep frequently used items on bedside table or within reach (water pitcher, cup, tissues, hairbrush, etc.) Be sure call light is within reach and encourage using it for assistance as needed. Respond promptly to all request for assistance. Ensure that resident is wearing appropriate footwear (shoes, bedroom slippers, non-skid socks) when ambulating or up in w/c (wheelchair… | 2015-08-01 |
| 9822 | 9822 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 279 | D | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, care plan review, and staff interview, the facility failed to ensure two (2) of four (4) resident's care plans were updated to reflect the development of pressure ulcers. Resident identifiers: #30 and #84. Facility census: 115. Findings include: a) Resident #84 On 04/02/12, review of the medical record for Resident #84 revealed an [AGE] year old paraplegic male. According to the medical record, he developed a stage I pressure ulcer on 03/20/12. The wound, measuring 3.5 cm in width, was identified by a local surgeon to whom the facility referred the resident due to multiple vascular ulcers to the bilateral lower extremities. The care plan review occurred on 04/03/12. This review revealed the facility had not addressed the development of the stage I pressure ulcer. The director of nursing (Employee #46) was informed that the facility had not included this issue in the resident's care plan on 04/03/12 at approximately 9:30 a.m. On 04/04/12, at approximately 4:00 p.m., the minimum data set registered nurse (Employee #39) confirmed the resident's peripheral vascular ulcers were care planned, but the stage I pressure ulcer on the coccyx was not addressed in the care plan. . . b) Resident #30 Review of the facility's treatment administration record found this resident had stage II pressure ulcer wounds to her bilateral heels. Further investigation found the facility did not have a care plan regarding the provision of care and treatment of [REDACTED]. On 04/03/12, at approximately 12:45 p.m., Employee #65, the assistant director of nursing, confirmed the facility failed to develop a care plan for the wounds. . | 2015-08-01 |
| 10221 | 10221 | PRINCETON HEALTH CARE CENTER | 515187 | 315 COURTHOUSE RD. | PRINCETON | WV | 24740 | 2010-04-15 | 514 | E | 0 | 1 | WIXO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, care plan review, and staff interview, the facility failed to maintain clinical records that were complete and accurate for two (2) of twenty-one (21) Stage II sampled residents. Resident #77's previous care plans addressing nutritional status were not available for review. Resident #128's weights were not recorded accurately in the electronic medical record. Additionally, the facility did not record the day, month, and year on which weights are obtained for residents who were being weighed monthly, which would interfere in accurately determining when a significant weight change occurred; this practice had the potential to affect more than an isolated number of residents. Resident identifiers: #77 and #128. Facility census: 118. Findings include: a) Resident #77 On 04/15/10 at approximately 1:00 p.m., medical record review for Resident #77 revealed she had a history of [REDACTED]. The nutritional status resident assessment protocol (RAP), dated 12/30/09, indicated this issue would be addressed in the resident's care plan. Further review of her medical record found documentation suggesting the resident's care plan had not addressed her nutritional status until 04/07/10. The assessment coordinator indicated the dietary manager had addressed the issue in prior care plans but had not saved copies of her work. She stated no one had ever shown the dietary manager how to save copies of her care plans and not delete them each time she updated her work. The resident's current care plan, dated 04/07/10, had addressed the problem of nutritional status, but no other documentation could support that the facility had care planned this issue prior to 04/07/10. b) Resident #128 1. Review of Resident #128's medical record revealed the weights had been inappropriately entered into the computer. The resident's admission weight were entered on the weight record as being 125.60#, and entered into the comprehensive admission asses… | 2015-06-01 |
| 9821 | 9821 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 272 | D | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, facility policy review, and staff interview, the facility failed to ensure a stage I pressure ulcer was assessed for one (1) of four (4) residents. The resident developed a stage I pressure ulcer which was not assessed according to the facility's policy on wound management. Resident identifier: #84. Facility census: 115. Findings include: a) Resident #84 On 04/02/12, review of the medical record for Resident #84 revealed an [AGE] year old paraplegic male. According to the medical record, he developed a stage I pressure ulcer on 03/20/12. The wound, measuring 3.5 cm in width, was identified by a local surgeon to whom the facility referred the resident due to multiple vascular ulcers to the bilateral lower extremities. The surgeon ordered a derma float air mattress, on 03/21/12, to promote wound healing. The order, dated 03/21/12, stated, "(physician name) ordered HILL ROM AIR MATTRESS FOR STAGE I ULCERS ON BUTTOCKS." The facility provided the resident with the air mattress. The assistant director of nursing (Employee #65) provided a copy of the facility's wound management policy on 04/03/12 at 9:40 a.m. The policy, dated January 2008, stated "Weekly Wound Rounds: The team makes rounds weekly to evaluate wound treatment and other care interventions. The licensed nurse evaluates the pressure ulcer and documents pressure ulcer healing using the pressure ulcer documentation form. If a pressure ulcer fails to show progress toward healing within 2-4 weeks the team reevaluates the treatment plan to determine whether to modify the current interventions. Individual nurses should not alter the treatment plan without input from the interdisciplinary team and the physician." The medical record contained non pressure and skin condition reporting forms for non pressure related areas on the resident's coccyx. As of 04/03/12, the last documentation on this form was dated 03/07/12. At that time the area on the coccyx was red, … | 2015-08-01 |
| 10828 | 10828 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-08-16 | 203 | D | 1 | 0 | XG6O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide an adequate discharge notice for one (1) of six (6) residents who had been discharged or transferred from the facility. Resident #67 was sent out to the hospital for an acute medical problem and discharged from the facility. A family interview revealed the facility did not notify the family that the resident was being discharged and would not be returning to the facility. There was nothing in the transfer / discharge notice given to the family at the time of the resident's transfer to the hospital that would indicate to the resident's family that the facility was discharging the resident with the intention of not allowing him to return. Resident identifier: #67. Facility census: 66. Findings include: a) Resident #67 Closed record review found Resident #67 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident was sent out to the hospital on [DATE] for an acute medical problem. Review of a copy of the transfer / discharge notice form that had been provided to the resident's family at the time of his transfer found form indicated the resident was being transferred to the hospital. The resident subsequently returned to the facility on [DATE]. Review of multidisciplinary notes found that, following the resident's return from the hospital on [DATE], the resident began exhibiting combative / abusive behaviors toward staff and other residents. Further review of multidisciplinary notes found the resident's medical condition continued to deteriorate and the facility encouraged the resident's medical power of attorney representative (MPOA) to agree to transferring the resident to the hospital for evaluation of acute medical problems, including [MEDICAL CONDITION], increased BUN (blood urea nitrogen), increased confusion, and low hemoglobin and hematocrit. The resident was transported to the hospit… | 2014-12-01 |
| 11260 | 11260 | MONTGOMERY GEN. ELDERLY CARE | 515152 | 501 ADAMS STREET | MONTGOMERY | WV | 25136 | 2010-06-17 | 325 | G | 1 | 0 | Q89G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide care and services in accordance with the resident's expressed advance directives to maintain adequate parameters of nutrition and health for one (1) of eleven (11) sampled residents. Resident #43 exhibited poor oral intake of food and fluids with a significant weight loss beginning in February 2010, and signs / symptoms of dehydration beginning in April 2010. The resident's physician orders [REDACTED]. According to weight records, Resident #43 weighed 146.8# on 08/19/09; on 06/09/10, she weighed 107#. This represented a 39.8# weight loss over a ten (10) month period. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident identifier: #43. Facility census: 49. Findings include: a) Resident #43 1. Record review revealed Resident #43 was initially admitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an assessment reference date (ARD) of 05/03/08, she weighed 159# with a height of 60 inches, was receiving a therapeutic diet and a dietary supplement with no nutritional problems noted at that time, to include no chewing or swallowing problems, and she had experienced no significant weight change. She subsequently discharged to a private home on 05/16/08. Resident #43 was readmitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an ARD of 04/13/09, she weighed 149# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. She was subsequently discharged to a private home on 07/15/09 and was readmitted on [DATE]. According to he… | 2014-07-01 |
| 11257 | 11257 | MONTGOMERY GEN. ELDERLY CARE | 515152 | 501 ADAMS STREET | MONTGOMERY | WV | 25136 | 2010-06-17 | 327 | G | 1 | 0 | Q89G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide care and services in accordance with the resident's expressed advance directives to maintain proper hydration and health for one (1) of eleven (11) sampled residents. Resident #43 exhibited poor oral intake of food and fluids with a significant weight loss beginning in February 2010, and signs / symptoms of dehydration beginning in April 2010. The resident's physician orders [REDACTED]. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident identifier: #43. Facility census: 49. Findings include: a) Resident #43 1. Record review revealed Resident #43 was initially admitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an assessment reference date (ARD) of 05/03/08, she weighed 159# with a height of 60 inches, was receiving a therapeutic diet and a dietary supplement with no nutritional problems noted at that time, to include no chewing or swallowing problems, and she had experienced no significant weight change. She subsequently discharged to a private home on 05/16/08. Resident #43 was readmitted to the facility from an acute care hospital on [DATE]. According to her comprehensive admission assessment with an ARD of 04/13/09, she weighed 149# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor indicated she left twenty-five percent (25%) or more of her food uneaten at most meals, but the assessor did not indicate the presence of any chewing or swallowing problems, and there was no significant weight change. She was subsequently discharged to a private home on 07/15/09 and was readmitted on [DATE]. According to her comprehensive admission assessment with an ARD of 08/29/09, she weighed 140# with a height of 60 inches and was receiving a therapeutic diet and a dietary supplement. The assessor in… | 2014-07-01 |
| 11346 | 11346 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2011-01-13 | 157 | D | I28Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide prompt notification, to the responsible party of one (1) of forty-two (42) Stage II sample residents, after the resident experienced a change in condition. Resident #120 became agitated while in the dining room on 11/12/10, and the nurse aides had to carry the resident back to her room due to her increased agitation, resistance of care, and physically aggressive behaviors. The resident's medical power of attorney representative (MPOA) did not learn of these events until 11/16/10. Resident identifier: #120. Facility census: 113. Findings include: a) Resident #120 On the night of 11/12/10, Resident #120 exhibited agitated behaviors that were atypical for her. According to documentation recorded by a licensed practical nurse (LPN - Employee #114), the resident was in the dining room by herself when she became agitated and started carrying around a wet floor sign, hitting the window of the dining room with the wet floor sign. The resident was soiled also due to incontinence. When nurse aides approached her and tried to get her to her room (in order to provide incontinence care), she became more agitated, hitting and kicking the nurse aides. Nurse aides eventually had to carry the resident from the dining room to her room, in order to change her out of her soiled clothes. On 01/06/11 at approximately 2:00 p.m., the social worker (Employee #134) provided a copy of documentation she had collected on 11/16/10. The documentation stated, "(Name), daughter and MPOA for (Resident #120), came into the office about 1:25 PM this date and stated that (name of Employee #73), CNA (certified nursing assistant), told her there was a rumor that 3 CNA's (sic) on south side turned in 3 CNAs from north side for abuse of (Resident #120). The story is that Friday, 11/12/10, night (Resident #120) was hitting and combative with staff. In an attempt to get her calmed t… | 2014-04-01 | ||
| 10902 | 10902 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-07-22 | 309 | D | 1 | 0 | SC5B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility provide necessary care and services to assist two (2) of eleven (11) sampled residents in attaining or maintaining their highest practicable physical well-being. Staff did not conduct a thorough physical assessment or notify the physician when Resident #60 had difficulty swallowing her medications and began to vomit. Staff did not initial the facility's bowel protocol timely when Resident #59 did not have a bowel movement on the third consecutive day. Resident identifiers: #60 and #59. Facility census: 58. Findings include: a) Resident #60 On [DATE] at approximately 3:00 p.m., review of Resident #60's medical record revealed she was admitted to the facility on [DATE] and discharged to a local hospital on [DATE]. An interview with a family member revealed the resident came to the facility for rehabilitation after sustaining a left [MEDICAL CONDITION] at home. The family member said the resident expired at a local hospital, and the hospital indicated she died from septic shock. The family member said the resident had a history of [REDACTED]. On [DATE], the resident had a basic metabolic panel (BMP) with the following abnormal values: - Glucose - 157 - High (normal range 65 - 99) - BUN - 46 - High (normal range 5 - 18) - Serum Creatinine - 2.15 - High (normal range 0.57 - 1.00) Employee #37 (a registered nurse) provided a copy of the resident's weights and vitals summary. The summary gave the following information: - [DATE]: 136.2 pounds. - [DATE]: Blood pressure - ,[DATE] , temperature - 96.8 , pulse - 60, respirations - 30 Nursing notes, dated [DATE] at 23:30 (11:30 p.m.) and [DATE] at 23:30 (11:30 p.m.), stated respectively that the resident had "decreased movement" and "difficulty" when swallowing her medications. A nursing note, on [DATE] at 22:25 (10:25 p.m.), stated, "... Observations: alert, even resp. skin w/d (warm / dry), took pm (evening) medication… | 2014-11-01 |
| 10486 | 10486 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2011-11-22 | 514 | D | 1 | 0 | JMJ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, facility policy review, and staff interview the facility failed to assure accurate and/or complete clinical information regarding one (1) of nine (9) sample residents. The facility failed to enter into the record any assessments for a four (4) day period during a decline in health care status which resulted in hospitalization . Resident identifier: #61. Facility census 117. Findings include: a) Resident #61 Review of the medical record for Resident #61 revealed that he was an [AGE] year old male admitted initially on 12/12/06 and recently readmitted on [DATE], after hospitalization . His admitting [DIAGNOSES REDACTED]. Review of the nurse's notes revealed, at 11:59 p.m. on 10/16/11, the resident had a "period of unresponsiveness" and the physician was notified. Labs and x-rays were ordered for 10/17/11. The laboratory results had several abnormal findings which were reported to the physician and the resident was transported to the hospital at 10:00 a.m. on 10/17/11. The hospital Admission summary which was done by the resident's attending physician, who treats him at the nursing home also, stated: "(Resident #61) is an eighty-four year old admitted to __ ___ Hospital with acute [MEDICAL CONDITION], dehydration, confusion, [MEDICAL CONDITIONS] symptoms and impaction." Review of the medical record revealed the resident had been on antibiotic therapy for a urinary tract infection from 09/22/11 - 10/04/11 with daily documentation of antibiotic tolerance. There was no evidence of any change in physical/mental status being assessed after that date, until 10/16/11 when the "period of unresponsiveness" occurred. There were NO nurse's notes in the medical record from 10/12/11 - 10/16/11. Additionally, there was no documentation during this period about the bowel status of the resident. The Medication Administration Record [REDACTED]. The care plan stated there would be monitoring of the resident's hy… | 2015-03-01 |
| 10485 | 10485 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2011-11-22 | 327 | G | 1 | 0 | JMJ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, facility policy review, and staff interview the facility failed to ensure that one (1) of nine (9) sampled residents received sufficient fluid intake to prevent dehydration resulting in the resident being hospitalized for [REDACTED]. Resident identifier: #61. Facility census 117. Findings include: a) Resident #61 A review of the medical record for Resident #61 revealed that he was an [AGE] year old male who had been determined to lack capacity to make health care decisions. His daughter was his medical power of attorney (MPOA). He required total care for all activities of daily living (ADLs), including feeding assistance, and was unable to make his needs known. He was admitted initially on 12/12/06 and recently readmitted on [DATE], after hospitalization . His admitting [DIAGNOSES REDACTED]. A review of the nurse's notes revealed, at 11:59 p.m. on 10/16/11, the resident had a "period of unresponsiveness" and the physician was notified. Labs and x-rays were ordered for 10/17/11. The laboratory results had several abnormal findings which were reported to the physician, and the resident was transported to the hospital, at 10:00 a.m. on 10/17/11. The abnormal results were: BUN 67 (normals) 7 - 18 mh/dL (09/06/11) 32 CREATININE 3.37 0.6 - 1.3 mg/dL 1.67 SODIUM 150.9 136 - 146 mmol/dL 139.3 CHLORIDE 112.3 98.0 - 107.0 mmol/L 104.5 The hospital Admission summary, which was done by the resident's attending physician, who treats him at the nursing home also, stated: "(Resident #61) is an eighty-four year old admitted to __ ___ Hospital with acute [MEDICAL CONDITION], dehydration, confusion, [MEDICAL CONDITIONS] symptoms and impaction." The physician stated the resident was treated with IV fluids and on discharge back to the nursing home (10/20/11) the resident was more awake, alert, his oral intake was back to his usual, and he was comfortable. The physician recorded being told by the resident's daug… | 2015-03-01 |
| 10483 | 10483 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2011-11-22 | 225 | D | 1 | 0 | JMJ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, facility policy review, and staff interview the facility failed to investigate and/or report, to the appropriate state agencies, allegations of possible neglect for one (1) of nine (9) sample residents. The facility failed to report bruising of unknown origin, an allegation the resident was dropped by facility personnel, and a complaint alleging the facility failed to assure adequate hydration for the resident. Resident identifier: #61. Facility census 117. Findings include: a) Resident #61 Review of the medical record for this resident revealed he was an [AGE] year old male who has been determined to lack the capacity to make health care decisions. His daughter was his(medical power of attorney (MPOA). The resident required total care for all activities of daily living (ADLs) and was unable to make his needs known. He was admitted initially on 12/12/06 and recently readmitted after hospitalization on [DATE]. His [DIAGNOSES REDACTED]. Review of the nurse's notes revealed the MPOA had made allegations of neglect to nursing staff on two (2) different occasions in October 2011. The notes stated the following: Complaint #1 10/4/11: 11:4 5 a.m. "POA (power of attorney) called, discussed res. now in scoop chair, questioning x-ray of coccyx, thinking possible tailbone fx. (fracture). Dr. ______ faxed." (per Nurse #18). 10/4/11: "5:40 p.m. "...now wants a donut for patients scoop chair, she's very irrate. States she thinks whirlpool dropped him." (per Nurse #167). 10/5/11: "Xray. Coccyx ordered per request of daughter for pain." Complaint #2 10/12/11: 6:50 p.m. "POA came to me saying she reported a bruise on her father's nose to the nurse from the night before, to see if we've found out what happened." (per Nurse # 167). Review, on 11/21/11, of the incident reports, resident concern forms, and reported allegations of mistreatment,abuse, and /or neglect for this period, failed to reveal any evidence … | 2015-03-01 |
| 11252 | 11252 | GRANT COUNTY NURSING HOME | 515151 | 27 EARLY AVENUE | PETERSBURG | WV | 26847 | 2010-07-16 | 157 | D | 1 | 0 | F0GM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, incident report review, family interview, and staff interview, the facility failed to notify the resident ' s legal representative or an interested family member and/or the physician in a timely manner of an accident with injury and/or potential for the need of medical intervention for one (1) of eight (8) sampled residents. Resident identifier: #19. Facility census: 107. Findings include: a) Resident #19 A review of Resident #19's medical record revealed she fell at 1:30 a.m. on Saturday, 05/22/10, and sustained a hematoma over the left eye. The incident report filed by the nurse (Employee #13) indicated the physician was not informed and that the daughter (not the resident's legal representative) was informed of the fall over thirteen (13) hours later at 2:40 p.m. on 05/22/10. At 8:20 p.m. on 05/23/10, a nurse recorded the following assessment in the resident's nursing notes: "97.8 122/58 76 21 (these are temperature, blood pressure, pulse, and respirations) Sats (blood oxygen saturation level) 80% room air; res (resident) up ambulating per normal; 0 (no) C/O (complaints of) discomfort except when palpating small hematoma upper medial L (left) eyebrow; retook Sats (sign for after) 5 min Sats now 70% then dropped to 64%; res with C/O feeling cold; fingers with bluish tinge and cold; O2 (oxygen) @ 2L (liters) via concentrator via N/C (nasal cannula) attached to res." This entry was made by entered by a licensed practical nurse (LPN - Employee #15). An assessment of the resident, at 5:00 a.m. on 05/24/10, stated: "... bruising remains to L eye and L side of face, bruising noted under R (right) eye also - has quarter size knot on inner side of eye brow L which is tender to touch." At 10:45 a.m. on 05/24/10, the resident's daughter filed a complaint with the social worker (Employee #14), because of the thirteen (13) hours that had lapsed before she was contacted. During a telephone interview with the daughter at… | 2014-07-01 |
| 5254 | 5254 | CLAY HEALTH CARE CENTER | 515142 | 1053 CLINIC DRIVE | IVYDALE | WV | 25113 | 2015-09-30 | 441 | E | 0 | 1 | 9ICN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, infection control log review, staff interview, and Guidelines for the Center for Disease Control and Prevention (CDC), the facility failed to maintain an effective infection control program designed to prevent and control, to the extent possible, the onset and spread of infection within the facility. The facility did not implement appropriate isolation precautions based on the type of infection (herpes [MEDICATION NAME], or shingles), for one (1) of its residents. This had the potential to affect more than a limited number of residents, staff, and visitors. Resident identifier: #10. Facility census: 58. Findings include: a) Resident #10 Review of the infection control log, on 09/29/15 at 3:10 p.m., found Resident #10 was diagnosed with [REDACTED]. Under the column labeled isolation, was the letter N, meaning none. During an interview with the interim director of nursing (DON) at this time, she said the letter N which denoted no isolation, was an error. She provided a copy of physician's orders [REDACTED]. The DON said they moved Resident #10 into a private room on 09/16/15. Upon inquiry as to why they did not utilize airborne precautions, she said although they had no policy or procedure on shingles precautions, they always followed CDC guidelines. She then checked the facility's copy of CDC guidelines and said they called for Airborne and Contact Precautions, rather than just contact precautions alone. Medical record review on 09/29/15 at 3:30 p.m. revealed a physician contact note, dated 09/16/15, which addressed the presence of red blisters to the left side of the resident's face and neck, and starting to appear on the upper chest. The physician ordered [MEDICATION NAME] (an anti-viral medication used to treat shingles), one (1) gram every eight (8) hours for five (5) days. The physician ordered the resident to move into a private room, and for staff to utilize contact precautions. A note dated 09/22/15 ad… | 2019-02-01 |
| 10546 | 10546 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2011-10-27 | 157 | D | 1 | 0 | Q1UQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, interview with the resident's guardian (a representative of the local West Virginia Department of Health and Human Resources - WVDHHR), and staff interview, the facility failed to notify the responsible party when one (1) of ten (10) residents was transferred to the hospital. Resident identifier: #67. Facility census: 84. Findings include: a) Resident #67 Medical record review for Resident #67 revealed this [AGE] year old female was originally admitted to the facility on [DATE]. She was adjudicated incapable of making medical and financial decisions, and the court appointed WVDHHR to act as her guardian and the County sheriff to act as her conservator. On 10/19/11, a local hospice agency evaluated and accepted Resident #67 to receive their services at the facility. Her terminal condition was related to an overall decline due to dementia and [MEDICAL CONDITION]. Further review of the medical record revealed Resident #67 was transferred to the hospital on [DATE] at 20:30 (8:30 p.m.) for: "Resident abdomin (sic) (abdomen) distented (sic) (distended). Complaint of pain in abdomin (sic). Not have fequent (sic) (frequent) bowel movements. Not eating well. Decreased bowel sounds." The nurses note stated the resident's physician and APS (WVDHHR) was notified of the transfer. On 10/26/11, the resident's court-appointed guardian, a representative from WVDHHR verified she learned of the resident's transfer to the hospital when she was notified the next day (10/26/11) by the hospice nurse. She denied having been notified by the facility on the evening of the transfer to the hospital. The WVDHHR representative stated she checked her e-mail, the hotline (used for reporting after hours) and her voice mail, and there was no message from the facility regarding Resident #67's transfer to the hospital. On 10/27/11 at 10:00 a.m., the director of nursing (DON) stated she spoke with Employee #43, the author of the nurses note on 1… | 2015-02-01 |
| 11007 | 11007 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-05-24 | 282 | D | 1 | 0 | BC7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation and staff interview, the facility failed to ensure treatments were provided as ordered by the physician for two (2) of eight (8) sampled residents. There was no evidence to reflect staff applied a barrier cream to the buttocks of Resident #104 after each incontinence episode, in accordance to a physician's orders [REDACTED]. Resident #112, who had an alteration in the skin integrity of her left heel and whose physician ordered that her heels be elevated when in bed, was observed on multiple occasions with her heels in direct contact with the mattress. Resident identifiers: #104 and #112. Facility census: 113. Findings include: a) Resident #104 Medical record review revealed Resident #104 was re-admitted to the facility on [DATE]. Medical information from the discharging hospital documented the resident as having "blanchable redness to the coccyx" upon her discharge from the hospital. Review of the admission nursing assessment dated [DATE] found, on the body diagram on page 3, no notations to indicate the presence of redness to the resident's coccyx / buttocks, and no pressure ulcer documentation form was initiated for Resident #104 on 12/18/10. Review of the physician's orders [REDACTED]." Review of the resident's treatment administration record (TAR) revealed this treatment was not provided as ordered on any shift from 12/19/10 to 12/28/10. The director of nursing (DON), when interviewed on 05/19/11 at 12:15 p.m., was unable to provide any evidence to demonstrate this treatment was provided as directed by the resident's physician. -- b) Resident #112 Medical record review revealed Resident #112 was re-admitted to the facility on [DATE], with three (3) pressure ulcers to the coccyx and a non-pressure wound to the left heel. The wound on the left heel was documented as having an ecchymosed area measuring 2.5 cm x 1.5 cm. On 04/19/11, a physician's orders [REDACTED]." Observation, on 05/23/11 at 9:5… | 2014-09-01 |
| 11281 | 11281 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2010-02-12 | 323 | D | 1 | 0 | 71J511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to ensure interventions and adequate supervision were provided to prevent falls for one (1) of three (3) residents reviewed for falls. Resident #39, who had a previous history of a fall from the bed with injury, had been assessed as being at high risk for falls and had planned interventions including the application of bed / chair alarms and a low bed with mats. Following a hospitalization , the facility failed to continue the safety interventions consistent with the resident's history to reduce the risk of falls and injury, and the resident sustained [REDACTED]. Resident identifier: #39. Facility census: 60. Findings include: a) Resident #39 Medical record review, on 02/12/10, disclosed this [AGE] year old male resident had been admitted to the facility from the hospital on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of nursing notes, dated 07/20/09, revealed the resident had bed and chair alarms to alert staff of his attempts to transfer without assistance and half side rails on each side of the bed to assist with bed mobility. This resident was described as being alert, confused, but able to answer simple questions. Following the resident's admission to the facility, nursing recorded the resident as dependent on staff for all activities of daily living, including transfer and bed mobility. Observation of this resident, on 02/12/10 at 11:00 a.m., found the resident was alert, answered simple questions, and was capable of some independent movement in the bed. Review of incident / accident reports found the resident had fallen from his bed at 1:15 p.m. on 08/13/09. The resident sustained [REDACTED]. Further review of the medical record found the resident had been transferred to the hospital for treatment of [REDACTED]. A fall risk assessment upon re-admission from the hospital, dated 11/19/09, identified the resident as being at high risk for fal… | 2014-07-01 |
| 9999 | 9999 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2010-03-11 | 315 | E | 0 | 1 | XVZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to ensure precautionary measures were taken and causative factors were investigated when four (4) of eighteen (18) sampled residents with urinary tract infections (UTIs) cultured positive for Escherichia coli (E. coli), a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. Resident #78 was incontinent of bowel and bladder and required extensive physical assistance with transfer, toilet use, and personal hygiene. This resident had a UTI on 02/27/10, and a laboratory report showed the infectious organism to be E. coli. This resident required treatment with [MEDICATION NAME] IM (intramuscular injection) every day for three (3) days. Resident #55 was incontinent of bowel and bladder and required extensive physical assistance with transfer, toilet use, and personal hygiene. This resident had a UTI on 01/04/10, and a laboratory report showed the infectious organism to be E. coli. Residents #70 and #81, who were also incontinent of bowel and bladder and required staff assistance with toileting, developed UTIs with E. coli cultured. Residents #70 and #81 also required antibiotic therapy. Residents #78, #55, #70, and #81. Facility census: 101. Findings include: a) Resident #78 Record review revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Medical record review, on 03/10/10, revealed a physician's orders [REDACTED]. Review of lab reports revealed the antibiotic therapy was to treat a UTI, and the infectious organism was E. coli, a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. Interview with the director of nursing (DON - Employee #42), on 03/10/10 at 11:30 a.m., confirmed the resident had a UTI with E. coli for which she received [MEDICATION NAME] injections. b) Resident #55 Record review revealed this [AGE] year old female, with [DIAGNO… | 2015-07-01 |
| 6156 | 6156 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2015-02-12 | 514 | D | 0 | 1 | M97U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to ensure two (2) of twenty-four (24) medical records reviewed in Stage 2 of the survey were accurate and complete. Resident #39's information related to hydration was not accurate regarding percutaneous endoscopic gastrostomy (PEG) tube fluid flushes. Resident #72's information related to pressure ulcers did not accurately reflect the status of a pressure ulcer. Resident identifiers: #39 and #72. Facility census: 78. Findings include: a) Resident #39 On 02/11/15 at 2:00 p.m., the medical record review for Resident #39 revealed the resident had a percutaneous endoscopic gastrostomy (PEG) tube. Further medical record review revealed a physician's orders [REDACTED]. The treatment administration record (TAR) for October 2014 revealed the resident began receiving a flush of 150 ml of water every four (4) hours on 10/01/14. A physician's orders [REDACTED]. Additional medical record review revealed, on 10/03/14 the dietitian recommended increasing the fluid flush to 150 ml q four (4) hours related to the resident's increased fluid needs. During an interview with Employee #45 (registered nurse/clinical reimbursement coordinator), on 02/11/15 at 2:45 p.m., she had no further information regarding the medical record discrepancy that the resident received 150 ml of water flushes every (4) hours, beginning on 10/01/14, prior to the physician's orders [REDACTED]. . . b) Resident #72 A Stage 1 interview, on 02/05/15 at 10:19 a.m., with Employee #78, a licensed practical nurse (LPN), and medical record review on 02/05/15 at 10:43 a.m., indicated Resident #72 had a suspected deep tissue injury (SDTI) on the left buttock. A wound observation, completed on 02/11/15 at 10:40 a.m., revealed the area was a deep crater with granulation tissue and with a narrow band of gray/brown substance around the wound edges. The surrounding tissue was dark pink/red with spotted necrotic ar… | 2018-05-01 |
| 10249 | 10249 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-01-11 | 323 | D | 1 | 0 | ZFKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide adequate supervision and / or assistive devices to promote prevention of falls. Additionally, the facility failed to assure assistive devices, designed to prevent falls, were installed properly to prevent accidents and to promote resident safety. Resident #55, who was known to be at risk for falls, was not provided with assistive devices. Resident #43 had a physician's orders [REDACTED]. The alarm had been applied incorrectly causing the alarm to malfunction. This practice affected two (2) of four (4) sampled residents who had experienced falls at the facility. Resident identifiers: #55 and #43. Facility census: 104. Findings include: a) Resident #55 The facility failed to provide any assistive devices for to prevent falls after the resident's second admission to the facility. The facility was aware the resident was at risk for falls and had experienced falls during his first admission to the facility. Medical record review found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. The hip fracture occurred shortly before the resident's admission to the facility. The resident was admitted with staples in his right hip as a result of the surgery. The resident's first fall at the facility occurred on 11/28/11, when he fell from his bed. The resident was sent to the hospital for evaluation and returned to the facility the same day with no injuries noted. The physician ordered fall mats to be placed at the bedside. On 11/29/11, the resident fell from his bed again. He was sent to the hospital and returned the same day with no injuries noted. The physician ordered a bed alarm to be placed on the bed at all times and a chair alarm to be used when the resident was up in his chair. On 11/30/11 the physician ordered bed bolsters to be placed on the bed at all times. On 12/02/11 the resident was admitted to the hospital for… | 2015-05-01 |
| 10307 | 10307 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 309 | D | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for two (2) of twenty-one (21) Stage II sample residents. One (1) resident had no follow-up assessments or monitoring after two (2) falls, and another resident's ill-fitting socks were causing indentations in the resident's lower legs. Resident identifiers: #31 and #12. Facility census: 34. Findings include: a) Resident #31 Medical record review, on 05/12/10, revealed this resident fell on [DATE], and was taken to the emergency room (ER) for evaluation. The next note, also on 03/08/10, described the resident being brought back from the ER and the resident's current condition. There were no nursing notes, between 03/08/10 and 03/15/10, seven (7) days later. The note on 03/15/10 did not mention the fall. There was no evidence the facility did any type of follow-up assessment or monitoring of the resident after the fall on 03/08/10. This resident fell again on 04/29/10 at 1930 (7:30 p.m.) and was taken to the ER. According to the medical record, the resident returned to the facility at 2200 (8:36 p.m.). There were no nursing notes regarding the fall and no evidence of any assessment or monitoring for the next three (3) days, until 05/02/10 at 1240 (12:40 p.m.). Interview with the vice president of patient care services (Employee #32), at 9:45 a.m. on 05/13/10, revealed nursing staff were supposed to complete follow-up assessments after any fall. Employee #32 reviewed the medical record and was unable to find any assessments following the fall on 03/08/10. Additionally, Employee #32 confirmed there should have been follow-ups between 04/29/10 and 05/02/10. -- b) Resident #12 At 2:00 p.m. on 05/12/10, during an interview with this resident, observation revealed the elastic tops of both of the resident's socks were making indentations in her legs just abo… | 2015-05-01 |
| 11414 | 11414 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2010-11-18 | 311 | D | 0ZJV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide treatment and services to maintain or improve the range of motion in both hands, for one (1) of eight (8) residents who had contractures of both hands and a physician's orders [REDACTED]. Resident identifier: #41. Facility census: 117. Findings include: a) Resident #41 Medical record review, on 11/16/10, revealed this resident had a physician's orders [REDACTED]. The order, dated 09/28/10, was for the protectors to be applied for eight (8) hours daily beginning at 9:00 a.m. each morning. Observations, at 2:00 p.m. on 11/16/10, at 9:30 a.m. on 11/17/10, at 1:00 p.m. on 11/17/10, and at 3:00 p.m. on 11/17/10, revealed neither hand had a palm protector in place. At 3:30 p.m. on 11/17/10, this information was brought to the attention of a licensed practical nurse (LPN - Employee #7), who confirmed the order and confirmed the palm protectors were not being used. | 2014-03-01 | ||
| 10323 | 10323 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2011-01-13 | 280 | D | 0 | 1 | I28Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility's interdisciplinary team failed to review and revise a resident's care plan to reflect changes made in her overall plan of care. The physician's orders [REDACTED]. The resident sustained [REDACTED]. Her care plan was updated to reflect the presence of the cast, but the care plan regarding the leg splint was not changed until its use was questioned on 01/11/11. One (1) of forty-two (42) Stage II sample residents was affected. Resident identifier: #1. Facility census: 113. Findings include: a) Resident #1 This resident was identified in Stage I of the survey as having contractures and selected for further review in Stage II. Observations of the resident found she did not have the splint on either leg or on her left hand on 01/04/11 or 01/05/11. She was found to have no splints on when observed on 01/11/11. Review of her current physician's orders [REDACTED]. She also had orders for a cast to her right leg and for: "Palmar splint to remain on left hand at all times. Remove QD (every day) for hand hygiene and skin care." There were no order changes regarding the use of the splints after she sustained a fracture to her right leg on 12/22/10. On 01/11/10 at 2:20 p.m., a nursing assistant (Employee #66) was observed rendering care to the resident. When asked about the leg splint, she said the resident did not have one on - she said the resident had a cast on her right leg and she (the nursing assistant) had not put the splint on. A minute later, she said she had been off work and maybe she should have put the splint on the other leg. She said she had not asked. At 2:31 on 01/11/11, Employee #66 reported she had asked and was told the splint had put on hold while the resident had the cast. At 2:10 p.m. on 01/12/11, the resident's medical record was again reviewed. On 01/11/11, an order had been written for: "(1) Hold until further notice: leg splint (symbol for 'secondar… | 2015-05-01 |
| 10322 | 10322 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2011-01-13 | 279 | D | 0 | 1 | I28Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility's interdisciplinary team failed, for two (2) of forty-two (42) Stage II sample residents, to develop a comprehensive care plan, based on a comprehensive assessment, to ensure the highest practicable levels of well-being for each resident. Resident #72, who had a [DIAGNOSES REDACTED]. The resident's care plan did not address positioning when eating, drinking, or taking medications. Resident #53 was observed smoking a cigarette with the oxygen tank not turned off. No care plan concerning the resident's smoking had been developed even though he was granted the privilege to smoke independently contrary to the facility's Smoking Evaluation tool, which indicated residents who used oxygen were to be supervised while smoking. Facility census: 113. Findings include: a) Resident #72 On 01/04/11 at 1:00 p.m., an interview with the resident was initiated. Observation at this time found he was lying in bed essentially flat with his head elevated no more than 10 degrees. At 1:07 p.m., Employee #100 (a licensed practical nurse - LPN) knocked on the closed door and entered the room to give the resident his medication. The nurse handed the resident the medication cup and a glass of water. The resident flexed his neck just enough to take a drink of water with which to swallow his medication. The nurse did not offer to elevate the head of the bed or assist him to a sitting position. Review of his care plan found a "Focus" statement of: "Resident is at nutritional risk r/t (related to) dx (diagnosis) of dysphagia, currently toleration (sic) regular diet." The goal included: "Residetn (sic) will have no s/s (signs / symptoms) of aspiration thru next review." The interventions were: "Honor food preferences within meal plan. Encourage 100% consumption of all fluids provided. offer (sic) meal substitutes / alternates as needed to encourage oral intake. regular (sic) diet as ordered. Off… | 2015-05-01 |
| 9936 | 9936 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2012-10-19 | 520 | F | 0 | 1 | 1T2X12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement and monitor actions to ensure that previously cited deficient practices, from the annual quality indicator survey (QIS), completed on 08/23/12 were corrected. The process did not ensure the practices were being consistently applied to prevent continuing non-compliance in regulatory areas where the facility's governing body was aware they had been deficient in the past. This re-visit found six (6) repeat deficiencies, F156, F241, F242, F280, F371 and F514. This practice had the potential to affect all residents of the facility. Facility census: 60. Findings include: a) Quality Assurance and Assessment (QAA) Committee During the re-visit survey, ending on 10/17/12, the survey team found continuing non-compliance with six (6) regulatory requirements cited during the facility's annual quality indicator survey (QIS) ending on 08/23/12. Actions by the facility's QAA committee did not correct these areas of deficiency and there was no evidence the QAA committee was aware, prior to the revisit, that these areas were still deficient. The following repeat deficient practices were identified: 1) The facility failed to ensure correct information about how to apply for and receive Medicare / Medicaid benefits was prominently displayed in the the facility. The facility also failed to ensure the correct address for the Medicaid fraud control unit was posted in the facility. 2) The facility failed to ensure residents were provided a dignified dining experience during the 08/23/12 QIS. The facility continued to fail to ensure residents seated at the same table were served at the same time, residents who shared a room received meal service at the same time, resident's were dressed in a dignified manner, and residents were fed in a dignified / respectful manner. 3) The facility failed to ensure a resident was al… | 2015-08-01 |
| 10317 | 10317 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 363 | E | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, menu review, recipe review, and staff interview, the facility failed to assure menus were followed for 1200 and 1500 calorie diets, and failed to assure there were menu plans for 2 gram sodium, cardiac, and renal diets. This practice affected fourteen (14) of thirty-three (33) residents who received nourishment from the dietary department. Facility census: 34. Findings include: a) Observation of meal service, on 05/11/10 at 12:05 p.m., revealed all residents were served a 3 ounce portion of meat. Review of the menu plan for this meal revealed the three (3) residents requiring 1200 and 1500 calorie diets were supposed to be served a 2 ounce portion of meat at this meal. At 12:30 p.m., this was brought to the attention of the dietary manager (DM - Employee #90), who confirmed the menu called for 2 ounces, yet 3 ounces were served to these residents. b) Medical record review revealed there were seven (7) residents with a physician's orders [REDACTED]. Review of the menu plan, for the noon meal on 05/11/10, revealed there were no specific menu plans for 2 gram sodium, cardiac, and renal diets. The menu did not indicate which food items were to be salt-free and/or fat-free for these diets. When this was brought to the attention of the DM, the DM stated the specific directives for these diets were on the recipes. The recipes for this meal were reviewed with the DM. There were no special directives for 2 gram sodium, cardiac, or renal diets on the recipes. . | 2015-05-01 |
| 10662 | 10662 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2011-09-09 | 279 | D | 1 | 0 | 6V5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, resident interview, and staff interview, the facility failed to develop and/or revise the comprehensive care plans for two (2) of eight (8) sampled residents. Resident #28 had a specific indicator regarding when she needed assistance in toileting, which was not incorporated into her care plan. Resident #48 was unable to activate the type of call light he was provided. Additionally, this resident required specific placement of a call light to afford the resident the ability to activate the device. Neither of these specific needs were a part of this resident's care plan. Resident identifiers: #28 and #48. Facility census: 77. Findings include: a) Resident #28 Review of this resident's medical record, on 09/08/11, revealed this confused resident was usually continent of urine. According to her care plan dated 08/04/11, the resident was "...occasionally incontinent of urine r/t (related to) dementia, impaired mobility, and impaired cognition." An interview was conducted with one (1) of the facility's assistant directors of nursing (ADONs - Employee #40) at 1:00 p.m. on 09/08/11. In discussing this resident's incontinence, Employee #40 revealed the resident "gets fidgety when she has to go to the bathroom." Further review of the resident's care plan noted the goal for the resident's incontinence was: "Resident will demonstrate improved urinary elimination control as evidenced by experiencing less than daily episodes of urinary incontinence." This goal was initiated on 08/04/11. The interventions for the goal were: "Complete a voiding diary and evaluate for patterns of incontinence at appropriate intervals. Encourage resident to consume fluids during meals. Complete an incontinence assessment at intervals according to policy and procedure. Observe for signs and symptoms of infection and report to physician if noted. Observe skin daily with ADL (activities of daily living) care and notify nurse of abnor… | 2015-01-01 |
| 10970 | 10970 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2011-06-29 | 246 | E | 1 | 0 | 6HEK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, resident interview, review of facility complaints, and review of resident council minutes for the months of April, May and June 2011, the facility failed to provide services with reasonable accommodation of resident needs and preferences, by failing to answer call lights in a reasonable amount of time. Random interviews with alert and oriented residents revealed it took an hour or more before staff would answered resident call lights. Review of the facility's internal complaint records and resident council meeting minutes found residents had made complaints to the facility about call lights not being answered timely. Observation, on 06/29/11 at 10:05 a.m., found a call light ringing outside of Resident #11's room. Many staff members had passed by this resident's door, and staff was seated at the nurse's station which was outside this room. No one responded to this activated call light until 10:20 a.m. This practice has the potential to affect all residents who could independently their call lights. Facility census: 89. Findings include: a) During the initial tour of the facility on 06/28/11 at 8:15 a.m., brief interviews were conducted with alert and oriented residents. Two (2) residents expressed concern about how long it took to get their call lights answered. Both residents stated it could take up to or over an hour for staff to respond. Review of the concerns / grievances received by the facility from either family members or residents disclosed complaints about call lights not being answered timely. During the month of April 2011, two (2) complaints were received by the facility about call lights not being answered timely; during the month of May 2011, one (1) resident complained about staff not answering the call light answered timely. Resident council minutes were reviewed for the months of April, May, and June 2011. During the May meeting, one (1) resident had complained about not getting… | 2014-10-01 |
| 11299 | 11299 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2010-03-25 | 314 | G | 1 | 0 | 4NN911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, review of Pressure Ulcers in Adults: Prediction and Prevention, Clinical Practice Guideline Number 3, AHCPR Pub. No ,[DATE]: [DATE], and staff interview, the facility failed to ensure two (2) of five (5) residents with pressure sores received the necessary services to promote healing and prevent new sores from developing. Resident #16, who was known to clench her hands, did not receive any services to prevent the development of Stage II and Stage II wounds to her palms caused by her fingernails; additionally, Resident #16's nurse contaminated the resident's coccygeal wound during a dressing change, and a nursing assistant massaged a reddened area over a bony prominence - an action known to cause tissue damage. Resident #59's nurse did not follow the current physician's orders [REDACTED]. Resident identifiers: #16 and #59. Facility census: 87. Findings include: a) Resident #16 1. Review of Resident #16's medical record found a nursing note, dated [DATE] at 10:40 a.m., stating, "Resident observed to have Stage III pressure area to palm of right hand caused by fingernail of third digit of right hand. Area cleansed /c (with) wound cleanser, dried and [MEDICATION NAME] powder applied. Hand roll placed in right hand. Left hand noted to have two 1 cm x 1 cm Stage I pressure areas to inside of fourth digit touching third digit. Also, 0.5 cm x 0.5 cm fluid filled Stage II pressure area noted to palm of left hand caused by fingernail of fourth digit ... Apply [MEDICATION NAME] power /c with hand rolls at all times ... Measurement of Stage III 1.5 cm x 2 cm x 0.5 cm ..." Review of the [DATE] treatment administration record (TAR) found the resident was receiving restorative nursing services to include passive range of motion, three (3) sets of ten (10) repetitions, to bilateral upper and lower extremities including all joints of fingers; these restorative services were originally ordered on [DATE]. The TAR d… | 2014-07-01 |
| 10242 | 10242 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2010-06-04 | 250 | E | 0 | 1 | 5XSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, staff interview, and resident interview, the facility failed to provide medically related social services to for four (4) of twenty-nine (29) residents in the Stage II sample. The facility failed to assure the needs of three (3) residents (who were confined to their rooms) were met, by failing to identify how the strict isolation was affecting each resident and failing to provide support in view of each resident's individual needs and preferences, customary routines, concerns, and choices. Residents #45, #49, and #52 were confined to, and required to remain in, single-occupancy rooms with no outside contact with other residents or planned activities. Additionally, the facility failed to assist Resident #46 when she was unable to locate her glasses. Resident identifiers: #45, #49, #52, and #46. Facility census: 48. Findings include: a) Residents #45, #49, and #52 Observations, medical record review, and resident and staff interviews found these three (3) residents were confined to, and prohibited from leaving, their rooms due to isolation procedures in conflict with accepted standards of practice. (See also citations at F223 and F441.) 1. Resident #45 Record review revealed Resident #45 tested positive for Methicillin-resistant staphylococcus aureus (MRSA) in her sputum on 05/27/10. She was moved from her usual room and placed into a single occupancy isolation room with the door closed. The resident had not been allowed to leave this room to interact with other residents and participate in activities from 05/27/10 through 06/02/10. An interview with the individual responsible for the day-to-day planning and organization of the activities department (Employee #1) was conducted at 4:14 p.m. on 06/01/10. She was asked what planned activities had been developed to address Resident #45's activity needs while she was alone and confined in the isolation room. Employee #1 stated she had not initiated a pl… | 2015-06-01 |
| 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 | ||
| 9992 | 9992 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2012-11-28 | 490 | F | 0 | 1 | R8A112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observations, and staff interviews, it was determined the facility was not administered in a manner which enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained his/her highest practicable well-being. There was a failure to fully implement the plan of correction for four (4) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 09/27/12. During the 11/28/12 revisit, deficiencies at F280, F281, F282, and F371 remained out of compliance. This had the potential to affect all residents in the facility. Facility Census: 47. Findings Include: a) The facility failed to revise a care plan for one (1) of ten (10) sample residents. The care plan for Resident #45 was not updated when she experienced a significant weight loss and began forgetting how to eat at times. The failure to revise care plans was cited at F280 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a repeat deficiency during the revisit which ended on 11/28/12. b) The facility failed to comply with facility policy and procedure and professional standards of practice during medication administration. A staff member initialed medications as given prior to the residents taking the medications. The failure to ensure services were provided in accordance with professional standards of practice was cited at F281 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a repeat deficiency during the revisit which ended on 11/28/12. c) The facility failed to follow physician's orders [REDACTED].#32, and failed to follow physician's orders [REDACTED].#31. The failure to ensure services were provided in accordance with the written plan of care was cited at F282 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a rep… | 2015-08-01 |
| 9991 | 9991 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2012-11-28 | 520 | F | 0 | 1 | R8A112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observations, and staff interviews, the facility's quality assurance program failed to develop and implement effective plans of action to correct identified quality deficiencies. Four (4) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 09/27/12, were still out of compliance during the re-visit survey which ended 11/28/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F280, F281, F282, and F371. This had the potential to affect all residents in the facility. Facility Census: 47. Findings Include: a) Staff interview with Employee #53 (QA Committee Contact Person), at 11:00 a.m. on 11/27/12, revealed the issues identified from the previous QIS survey had been addressed with the Quality assessment and assurance committee (QA Committee). Employee #53 confirmed the QA Committee had been presented with the entire plan of correction at their meeting on 11/01/12. Employee #53 confirmed the plan of correction, including those in which the QA committee was not expressly mentioned, was discussed during this meeting. The QA committee did not ensure the deficient practices cited during the survey which ended 09/27/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F280, F281, F282, and F371. They remained out of compliance when evaluated for compliance during the revisit survey which ended 11/28/12. b) The facility failed to revise a care plan for one (1) of ten (10) sample residents. The care plan for Resident #45 was not updated when she experienced a significant weight loss and began forgetting how to eat at times. c) The facility failed to comply with facility policy and procedure and professional standards of practice during medication administration. A … | 2015-08-01 |
| 9925 | 9925 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-10-05 | 490 | F | 0 | 1 | TTVD12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observations, staff interviews, and policy review, the facility was not administered in a manner in which its resources were used effectively and efficiently to ensure optimum quality of care for each resident. The facility failed to provide individualized services to assist each resident in attaining or maintaining the highest practicable physical, mental, and/or psychosocial well-being. Six (6) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 07/24/12 were still out of compliance during the re-visit survey which ended 10/05/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F279, F280, F309, F371, F431, and F517. This had the potential to affect all residents in the facility. Facility Census 49. Findings Include: a) Staff interview with Employee #34, the Quality Assurance (QA) committee contact person, at 2:00 p.m. on 10/04/12, revealed the issues identified from the previous QIS survey had been presented to the facility's QA committee. The facility's administrative personnel were part of the QA committee. The facility's administrative personnel did not ensure the deficient practices cited during the survey which ended 07/24/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F279, F280, F309, F371, F425, and F517. They remained out of compliance when evaluated for compliance during the re-visit survey which ended 10/05/12. b) Staff interview and medical record review revealed the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care, a resident who received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MED… | 2015-08-01 |
| 11412 | 11412 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 328 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents, whose closed record was reviewed, received proper care and treatment for [REDACTED]. Resident #119 was [AGE] years old female who was admitted to the facility from the hospital following a surgical procedure for a [MEDICAL CONDITION]. During a prolonged hospital stay, she was also treated for [REDACTED]. Review of Resident #119's medication administration records (MARs) revealed she was frequently noted to refuse her inhalation treatments; these refusals were not communicated to her attending physician. Facility policy required licensed nursing staff to collect and record physical assessment data regarding the resident's respiratory status before and after the administration of each inhalation, as well as the resident's response to each treatment after it was completed. Review of her nursing notes and MARs found no evidence this physical assessment data was being collected and recorded in accordance with facility policy. The resident subsequently exhibited an acute change in condition, which the certified nurse practitioner ultimately considered was attributable to possible pneumonia. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 for a surgical repair of a [MEDICAL CONDITION], during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - 2. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record… | 2014-03-01 | ||
| 11410 | 11410 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 281 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, licensed nursing staff at the facility failed to follow facility policy regarding the administration of aerosolized medication to one (1) of six (6) sampled residents whose closed record was reviewed. According to her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to facility policy, licensed nursing staff was to collect and record physical assessment data regarding the resident's respiratory status prior to and following the administration of an aerosolized medication and the resident's response to each treatment after administration was complete. Review of documentation recorded in the resident's nursing notes and on the medication administration records (MARs) found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment, and there was no documentation recorded describing the resident's response to each treatment. Staff interviews confirmed these assessments were not being done, thus not meeting professional standards of quality. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation l… | 2014-03-01 | ||
| 10793 | 10793 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2011-11-03 | 279 | D | 1 | 0 | PBEB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to develop an episodic care plan with measurable objectives and goals to address the treatment of [REDACTED]. Resident #25 was found to have a blister on the right upper thigh which required medical treatment, and no care plan had been developed to address this change in condition and treatment. Resident identifier: #25. Facility census: 57. Findings include: a) Resident #25 Review of incident / accident reports, on 11/02/11, disclosed a dime-sized blister had been found on the top of Resident #25's right upper thigh at 10:00 a.m. on 10/10/11. "Resident states she doesn't know what it is but it itches." Review of nursing notes found an entry, recorded at 2:07 p.m. on 10/10/11, stating (quoted as typed): "Resident has a 0.3cmx0.2cm pink slightly raised blister on the top of her right thigh, that appears to have very scant amount of fluid inside. Resident states that it itches occasionally but does not hurt. Resident aware of treatment of [REDACTED]." Further review of the medical record found no episodic care plan had been developed to address the care and treatment of [REDACTED]. Review of the facility's blister protocol, which was provided by the administrator (Employee #26) on 11/03/11, revealed Item #4 (under "Documentation") that an episodic care plan was to be developed. In an interview with the director of nursing (DON - Employee #5) on 11/03/11 at 11:00 a.m., she confirmed a care plan had not been developed to address the care and treatment of [REDACTED]. . | 2014-12-01 |
| 10697 | 10697 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 323 | G | 1 | 0 | UBFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to ensure three (3) of forty-five (45) Stage II sample residents received adequate supervision and assistance devices to prevent avoidable accidents, resulting in actual harm to one (1) resident. Additionally, staff failed to follow the facility's Fall Management Program with respect to documentation, assessment, care planning, and post-fall evaluations. Resident #206 was admitted on [DATE] and sustained five (5) falls between 06/22/11 and 07/18/11; two (2) of the falls required transfer to the hospital, one (1) of which resulted in a fractured clavicle. The resident had diminished cognitive ability due to malignant brain cancer. The interdisciplinary team (IDT) did not develop new interventions that were appropriate for a resident with diminished cognitive ability, relying upon the resident to exercise good judgment to promote her own safety (e.g., instructing the resident to ask for staff assistance with transfers). The facility kept the same interventions in place after the resident continued to sustain falls with serious injuries. Resident #214 sustained a fall on 07/26/11, and staff did not complete a physical assessment of the resident after the fall, nor did they follow the other post-fall action steps outline in the facility's policy. Resident #37 had a care plan intervention for his bed to be in the lowest position due to falls. Observation revealed this intervention was not implemented as planned. Resident identifiers: #206, #214, and #37. Facility census: 105. Findings include: a) Resident #206 1. The medical record for Resident #206, conducted on 08/04/11 at approximately 12:00 p.m., revealed this [AGE] year old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Medical records from Resident #206's hospital stay prior to her admission to the nursing home included a form titled "Determination of Capacity / … | 2014-12-01 |
| 11408 | 11408 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 157 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to notify the physician of a potential need to alter treatment for one (1) of six (6) sampled residents whose closed record was reviewed. Resident #119 was admitted to the facility on [DATE] following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for acute [MEDICAL CONDITION] (ARF), and her discharge orders from the hospital included [MEDICATION NAME] inhalation treatments every four (4) hours (at regular intervals six (6) times a day). According to documentation on her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for this resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for ARF. Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated 2 = Drug Refused"). Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short… | 2014-03-01 | ||
| 8219 | 8219 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 205 | E | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to provide a discharge/transfer bed-hold policy notice that included the contact names and information should the resident wish to appeal the discharge/transfer from the facility. This was found for three (3) of three (3) residents reviewed for notice of the bed-hold policy at the time of transfer. This had the potential to affect all residents discharged /transferred from the facility. Resident identifiers: #116, #44, and #123. Facility census: 112. Findings include: a) Resident #116 Medical record review, on 07/23/13 at 11:00 a.m., revealed the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 06/27/13. The resident was readmitted to the facility on [DATE], then transferred again on 07/04/13. No evidence was found in the resident's medical records that the resident or family was given a transfer/discharge bed-hold policy at the time of either transfer from the facility. During an interview on 07/24/13 at 3:00 p.m., with Employee #123, the director of nursing (DON), she was unable to provide evidence the bed-hold policy, either verbal or written notice, was provided to the resident/family. In addition, a copy of the written notice of transfer was not included in the resident's medical record as required by facility policy. b) Resident #44 Medical record review on 07/23/13 at 1:00 p.m., found the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 07/18/13. No evidence was found in the resident's medical records that the resident/family was given a transfer/discharge bed-hold policy upon transfer from the facility. During an interview, on 07/24/13 at 3:00 p.m., with the DON, she was unable to provide evidence the bed-hold policy notice, either verbal or written, was provided to the resident/family. In addition, a copy of t… | 2016-07-01 |
| 10926 | 10926 | MCDOWELL NURSING AND REHABILITATION CENTER, LLC | 515162 | PO BOX 220 | GARY | WV | 24836 | 2011-07-08 | 224 | G | 1 | 0 | 34ZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to provide necessary care and services to avoid physical harm for one (1) of five (5) sampled residents. The facility failed to appropriately monitor Resident #200's glucose levels, failed to assess and monitor a reddened area on the resident's penis, and failed to assess and monitor this resident's intake and output. Resident #200 was admitted to the hospital on [DATE], totally unresponsive, with [DIAGNOSES REDACTED]. Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 1. Record review revealed Resident #200 was an [AGE] year old white male admitted to this facility on 11/09/10 with [DIAGNOSES REDACTED]. Review of the history and physical, completed by his treating physician on 11/15/10 documented, the resident as being alert and oriented x 4. Review of the admission orders [REDACTED]. Further review found no orders for assessment of the resident's blood glucose levels. - Review of facility policy entitled "Nursing Care of the Adult Diabetes Mellitus Resident" (revised 05/01/06) found, under the section entitled "Purpose", the following language: "... 2. Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. 3. Recognize, assist and document the treatment of [REDACTED]. The section entitled "General Guidelines" contained the following language: "If you observe a diabetic resident or is a diabetic resident complains of any of the following symptoms, report it to the Unit Chare Nurse immediately. [MEDICAL CONDITION] d. malaise (appears tired)... b. lethargy (drowsiness)..." The policy did not provide instructions to the charge nurse for what interventions to provide should the above symptoms be observed or reported. - Review of a complete blood count (CBC) laboratory test from 11/12/10 that the resident's glucose was 265 mg/dl. The physician ordered an Hgb A1c test. The medical record found no evidence this ordered… | 2014-11-01 |
| 10316 | 10316 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 278 | D | 0 | 1 | MM9U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and observation, the facility failed to assure the minimum data set (MDS) assessment accurately reflected the physical status of two (2) of twenty-one (21) Stage II sample residents. Resident identifier: #31 and #33. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., observation made as the resident spoke found broken and carious teeth. The resident described her teeth as being in "pretty bad shape" and opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. The resident's initial minimum data set (MDS), with an assessment reference date (ARD) of 02/07/10, was reviewed. Section L, relative to oral / dental status, did not accurately identify the condition of the resident's teeth. L.1.d "Broken loose, carious teeth" was not marked on the MDS, even though this condition had to have existed upon the resident's admission on 01/26/10. -- b) Resident #33 When interviewed on 05/04/10 related to the presence of an indwelling Foley urinary catheter for this resident, Employee #28 (a licensed practical nurse and the medical record coordinator) stated this resident had a Foley catheter due to severe [MEDICAL CONDITION] of the lower legs. The resident was stated to be voiding down her legs, making the skin condition worse. When reviewed on 05/12/10, the resident's medical record revealed the resident was admitted to the Extended Care Unit (ECU) of the facility on 03/18/10. She had been hosptalized on [DATE], when, according to hospital reports, she presented to the emergency department with pain in her right leg. Her provisional [DIAGNOSES REDACTED]. The resident was re-hosptalized on [DATE] and remained hospitalized until 04/26/10, at which time, according to a nursing readmission assessment on this day, the resident returned to the ECU with an indwelling Foley urinary… | 2015-05-01 |
| 10255 | 10255 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-09-26 | 279 | E | 0 | 1 | FJI611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and staff interview the facility failed to develop interdisciplinary plans of care for residents in the areas of activities of daily living, nutrition, [MEDICAL TREATMENT], range of motion, and unnecessary medications. This was true for three (3) of thirty-one (31) residents reviewed in Stage 2 of the quality indicator survey. Resident identifiers: #204, #145, and #93. Facility census: 109. Findings include: a) Resident #204 1) During an interview with the resident on 09/18/12 at 2:09 p.m. the resident stated the staff do not help me brush my teeth, they just give me a toothette and tell me I can do it myself. She stated, " I can do it myself but I would like a toothbrush and toothpaste." The Resident further explained she recently fell at home and broke her back. She stated, "I am not suppose to walk alone and the doctor told me if I fell again, I might not be so lucky, I could be paralysed." She stated if someone would help her to the sink she could brush her teeth. "Once I get there I can use the toothbrush myself". The resident also stated that she could put her clothes on but someone had to get them out of the closet for her. "I have all these needles and tubes coming out of my neck and I am afraid I will pull them out while dressing." "I also need a little help with my pants, shoes and socks but the staff tell me I can do this myself." Review of the admission MDS (minimum data set) with ARD (assessment reference date) of 09/04/12, section (G) functional status, found the resident required extensive assistance of one staff member with dressing and personal hygiene, which included brushing teeth. Extensive assistance was described on the MDS as "Resident involved in activity, staff provide weight-bearing support." Review of the facility form entitled, "Resident Functional Performance Record, (completed by the nursing assistants), found the resident has performed the activities of groom… | 2015-05-01 |
| 11451 | 11451 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-05-12 | 279 | D | 1I0H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and staff interview, the facility failed to develop a care plan for one (1) of thirty-nine (39) Stage II sampled residents who had distinct food preferences. Resident identifier: #90. Facility census: 129. Findings include; a) Resident #90 Record review revealed this resident was admitted to the facility on [DATE]. Interview with this resident, on 05/03/11 at 5:44 p.m., revealed he had many food preferences which were not honored by the dietary department. The resident further stated it was " not necessarily that I don ' t like them, they don ' t like me " . During the survey, it was confirmed the resident was receiving foods which were noted as dislikes on his tray card. Review of the resident's comprehensive care plan, on the morning of 05/05/11, revealed nothing regarding food preferences and/or foods that did not " like him " . This was brought to the attention of the dietary manager (DM - Employee #21) at 10:45 a.m. on 05/05/11. At that time, the DM confirmed there was no care plan for the resident's food preferences. On 05/06/11, the DM provided a care plan, dated 05/06/11, related to preferences for Resident #90. It stated as the problem, "Resident will report he receives food not on his preferences even if they were not served that day." There were no associated goals and interventions to assure the resident's known preferences were honored and/or to assure the resident's food preferences were periodically updated. Additionally, the problem, as stated, was not the problem expressed by the resident. The resident was getting foods he previously told the facility he did not like and that did not " like him " . His newly written care plan did not address this problem at all. On 05/10/11 at 4:55 p.m., an interview regarding this care plan was conducted with the director of nursing (DON - Employee #49). The DON agreed a care plan for the resident to report to staff was not a sufficient m… | 2014-03-01 | ||
| 10290 | 10290 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2011-04-14 | 309 | D | 0 | 1 | KZR811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, observation, staff interview, and policy review, the facility failed to ensure a resident, with physician's orders [REDACTED]. This practice affected one (1) of thirty-seven (37) Stage II sample residents. Resident identifier: #134. Facility census: 115. Findings include: a) Resident #134 1. Medical record review, conducted on 04/06/11, revealed this [AGE] year old female resident attended [MEDICAL TREATMENT] three (3) times per week related to a [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. On 11/23/10, the physician ordered a daily fluid restriction as follows (quoted as typed): "Fluid restriction 1700cc's: dietary to provide 240ml with breakfast and dinner and 480ml with lunch. Nursing to provide 120 on 11-7: 360 on 7-3, and 240 on 3-11." (NOTE: 1 cubic centimeter (cc) = 1 milliliter (ml).) Subsequent record review revealed the resident was determined, on 04/09/11, to not possess the capacity to understand and make her own medical decisions. -- 2. In an interview on 04/11/11 at approximately 2:00 p.m., the resident reported the facility had previously restricted how much fluid she drank, but she did not think they were doing that now. Observation found a pitcher with water on her overbed table. The resident said she did not like people telling her what to do, and when she wanted something to drink, she did not want anyone telling her she could not do something. -- 3. Review of Resident #134's care plan found the following problem statement (Date Initiated: 11/22/10): "Risk for fluid output exceeding intake characterized by fluid volume deficit; dry skin and mucous membranes, poor skin turgor and integrity related to: decreased independent access to fluids, nausea / vomiting, uncontrolled health conditions, pain, laxatives / enema use, [MEDICAL TREATMENT], 1700 ml fluid restriction, able to consume fluids independently after set up." The goal associated with this prob… | 2015-05-01 |
| 10664 | 10664 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2011-09-09 | 315 | D | 1 | 0 | 6V5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, policy review, and staff interview, the facility failed to assure one (1) incontinent resident, of eight (8) sampled residents, was provided services to restore as much normal bladder function as possible. This resident was not assessed or provided services to achieve or maintain as much normal urinary function as possible when her catheter was removed and/or as she continued to experience frequent episodes of incontinence. Resident identifier: #37. Facility census: 77. Findings include: a) Resident #37 Medical record review, on 09/08/11, revealed this resident was admitted to the facility from the hospital on [DATE]. She had a urinary catheter upon admission. On 04/04/11, the catheter was removed. There was no evidence the facility assessed the resident for a plan to restore as much normal bladder function as possible when the catheter was removed. There was also no assessment regarding the type of urinary incontinence, or the causes of the incontinence, to allow for the provision of an individualized program or interventions which addressed the incontinence. An interview was conducted with the resident at 12:15 p.m. on 09/08/11. At that time, the resident stated she could feel the urge to void. Additionally, the resident said she would like to participate in bladder retraining if the facility determined it was appropriate for her. She expressed a desire to be assisted in becoming continent if at all possible. At 1:00 p.m. on 09/08/11, an interview was conducted with one (1) of the facility's assistant directors of nursing (ADONs - Employee #40). The ADON stated the facility should have initiated a three (3) day continence management diary when the catheter was removed, to assess the resident's continence / incontinence. Based on the results of the diary, the resident should have been offered a restorative urinary continence management program, or other toileting program as appropriate. U… | 2015-01-01 |
| 11142 | 11142 | SPRINGFIELD CENTER | 515188 | ROUTE 1 BOX 101-A | LINDSIDE | WV | 24951 | 2011-04-15 | 309 | E | 1 | 0 | DRNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, staff interview, and observation, the facility failed to ensure each resident received the care and services to maintain his or her highest practicable levels of well-being in accordance with the plan of care. A resident experienced an acute episode of gastrointestinal (GI) bleeding, but his blood pressure was not checked for more than thirty (30) minutes after the staff was made aware he was ill. Another resident had an order for [REDACTED]. A resident who had recently begun to gain weight after having experienced a significant weight loss. He had also had declines in his abilities to perform activities of daily living. This resident was observed to not be positioned to facilitate feeding himself. Six (6) residents were found to have orders for nutritional supplements. The orders included instructions to record the percentage of the supplements the resident consumed. These percentages were not consistently recorded as ordered for six (6) of six (6) residents. Resident identifiers: #20, #26, #47, #9, #6, #26, #32 and #50. Facility census: 51. Findings include: a) Resident #20 On 04/13/11 at 6:38 p.m., this resident motioned as though needing assistance. He said he was tired, did not feel well, and needed to go back to bed. When asked if he had rung his call bell, he said he had not - that he could not reach it. The resident was sitting up in a wheelchair with his overbed table in front of him. His call bell button was lying on his bed, several feet away. The overbed table was between the resident and the call button. The resident rang his call bell at 6:40 p.m. after being handed his call bell. At 6:43 p.m., a nursing assistant came to the door to see what he needed. He told her he needed to go to bed because he did not feel well. The nursing assistant had a bag of soiled linen in her hand, so she could not enter the room. She summoned another nursing assistant and said she would be back a… | 2014-08-01 |
| 10223 | 10223 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2010-06-04 | 313 | D | 0 | 1 | 5XSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, staff interview, and observation, the facility failed to ensure one (1) of twenty-nine (29) Stage II sample residents received appropriate care and services to address his vision needs. The resident's glasses were missing, and there was no evidence to reflect the facility attempted to locate the missing glasses or obtain a replacement pair of glasses for him. Resident identifier: #46. Facility census: 48. Findings include: a) Resident #46 Review of Resident #46's medical record, on 05/27/10 at approximately 12:00 p.m., revealed an admission nursing assessment dated [DATE], which indicated Resident #46 wore eyeglasses. Further medical record review revealed a physician's orders [REDACTED]. Review of the resident's care plan, conducted on 05/27/10, found the facility identified the resident was at risk of falling. Interventions to promote the resident's safety included keeping his glasses clean and within his reach. In an interview on 05/27/10 at approximately 3:30 p.m., Resident #46 reported he did have glasses, and the glasses did help him see better, but he did not know where they were. In an interview on 05/27/10 at approximately 4:00 p.m., the director of nurses (DON - Employee #25) and the social worker (Employee #152) reported having no knowledge that the resident wore glasses and expressed having no idea where his glasses were. Staff did acknowledge that a pair of brown-framed glasses was on one (1) of the medication carts, but they did not know if these belong to Resident #46. Observation of Resident #46's room, on 06/04/10 at approximately 10:00 a.m., found a pair of brown-framed glasses lying on the resident's overbed table. When interviewed, Resident #46 did not know if they belonged to him. Interview shortly thereafter, with a licensed practical nurse (LPN - Employee #50) who had given the resident his medications, revealed the LPN had never seen these glasses before and she did… | 2015-06-01 |
| 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 |
| 11348 | 11348 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 514 | D | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, and staff interview, the facility failed to maintain a complete clinical record for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was observed with excessive bruising to bilateral upper extremities, and there was no documentation that two (2) of three (3) weekly body audits had been completed in the month of December 2010. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, "We know we have a problem with documentation, and we are working on it." Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. (See also citation at F309.) | 2014-04-01 | ||
| 11347 | 11347 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 309 | D | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, staff interview, and resident interview, the facility failed to provide necessary care and services for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was receiving blood thinners and was observed with excessive bruising to bilateral upper extremities. There was no documentation that the use of blood thinners was being monitored for this resident. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of recent laboratory results, dated 09/09/10 and 11/08/10, found no laboratory results used for monitoring the effectiveness of the blood thinner to regulate clotting. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 4:00 p.m., Resident #15 reported, "I can barely just touch or scratch myself and I bruise. I am on blood thinners, and I think it needs to be checked. I was going to talk to my doctor about it, but I haven't seen him." In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, "We know we have a problem with documentation, and we are working on it." Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. Interview with the licensed practical nurse (LPN) assigned to Resident #15 (Employee #159), on 12/22/10 at 5:20 p.m., revealed he was not aware of any bruising to Resident #15's bilateral upper extremities. . | 2014-04-01 | ||
| 10822 | 10822 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2011-08-17 | 329 | D | 1 | 0 | 8UE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of a nursing drug handbook, and staff interview, the facility failed to ensure the medication regimen of one (1) of five (5) sampled residents was free from unnecessary drugs without adequate monitoring and without adequate indication for its use. Resident #128 received the antispastic medication [MEDICATION NAME] for approximately five (5) days before she was transferred to a local emergency department due to lethargy and decreased level of consciousness. The medical record revealed no documentation as to why the resident needed the medication, and there was no evidence to reflect nursing staff was routinely monitoring the resident for common adverse side effects affecting the central nervous system. Resident identifier: #127. Facility census: 126. Findings include: a) Resident #128 Record review revealed this [AGE] year old female, who was admitted to the facility on [DATE], was transported to the local emergency roiagnom on [DATE] and did not return to the facility. Her [DIAGNOSES REDACTED]. She had also received antibiotic treatment for [REDACTED]. diff) - a bacterial infection that may develop after prolonged use of antibiotics during healthcare treatment. - A physician's orders [REDACTED]. In 3 days increase to 20 mg one tab po tid." - Review of the nursing notes revealed an entry dated 06/29/11 at 17:00 (5:00 p.m.), stating (quoted directly as stated in the electronic medical record): "Called to resident room by PTA (physical therapy assistant). Stated resident 'doesn't seem right.' Resident noted to be slumped over to the right side in wheelchair. Lethargic but arousable. Oriented to self, but not to place or time. Vital signs stable, afebrile, Blood sugar 145. Resident started flailing arms while myself was in the room. Stated she has been 'blacking out and I don' know where I am.' Resident states that she wants us to send her to the hospital 'to get checked out.' Notified Dr. (name) of reside… | 2014-12-01 |
| 10820 | 10820 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2011-08-17 | 309 | D | 1 | 0 | 8UE611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of a nursing drug handbook, and staff interview, the facility failed, for one (1) of five (5) residents, to assess / monitor the resident after starting new medication which was known to produce the adverse side effect of decreased level of consciousness. The resident later needed emergency medical treatment after experiencing symptoms of lethargy and a decrease level of consciousness. Resident identifier: #128. Facility census: 126. Findings include: a) Resident #128 Record review revealed this [AGE] year old female, who was admitted to the facility on [DATE], was transported to the local emergency roiagnom on [DATE] and did not return to the facility. Her [DIAGNOSES REDACTED]. She had also received antibiotic treatment for [REDACTED]. diff) - a bacterial infection that may develop after prolonged use of antibiotics during healthcare treatment. - A physician's orders [REDACTED]. In 3 days increase to 20 mg one tab po tid." - Review of the nursing notes revealed an entry dated 06/29/11 at 17:00 (5:00 p.m.), stating (quoted directly as stated in the electronic medical record): "Called to resident room by PTA (physical therapy assistant). Stated resident 'doesn't seem right.' Resident noted to be slumped over to the right side in wheelchair. Lethargic but arousable. Oriented to self, but not to place or time. Vital signs stable, afebrile, Blood sugar 145. Resident started flailing arms while myself was in the room. Stated she has been 'blacking out and I don' know where I am.' Resident states that she wants us to send her to the hospital 'to get checked out.' Notified Dr. (name) of residents request. Order received to send to ER for evaluation. Notified residents son per her request of ambulance transport to ER. After calling 911 for transport to hospital, notified by residents son that resident 'wont wake up.' Assessed resident again. Unresponsive. BP 90/68, HR 58 Resp 14. Remained with resident until (… | 2014-12-01 |
| 9803 | 9803 | MANSFIELD PLACE | 515129 | PO BOX 930 | PHILIPPI | WV | 26416 | 2012-09-06 | 386 | D | 1 | 0 | GYM311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of documents from the hospital, review of consultant reports, and staff interview, it was determined the facility failed to ensure the attending physician had an active role in the assessment and care of a left heel pressure ulcer for one (1) of one (1) resident with a pressure ulcer in a sample of six (6) residents. Resident #21 developed a pressure sore on the left heel on 02/23/12 which was treated. Gangrene later developed and resulted in the resident having an above the knee amputation. There was no evidence in the physician's progress notes of any assessment of the wound and its care and treatment. There was no evidence found in the medical record indicating the physician has assessed the progression of the pressure ulcer. Resident identifier: #21. Facility census: 56. Findings include: a) Resident #21 Resident # 21 was a [AGE] year old lady admitted [DATE]. The resident's [DIAGNOSES REDACTED]. During a review of nursing notes, it was discovered the pressure area on the left heel was discovered on 02/23/12. At that time the left heel was described as being pink to purple. An order was received to apply skin prep to both heels every shift for 10 days and re-evaluate. Review of physician's orders found the treatment of [REDACTED]. It was also discovered nursing staff had orders to continue with the Skin Prep to the left heel ulcer from 02/23/12, to approximately 08/02/12, when the order was changed to [MEDICATION NAME] according to wound care note dated 08/02/12. On 07/23/12, nursing sent a request to the physician for a wound consult for the left heel due to non-healing. On 08/15/12 the resident was transported to a wound care center for consultation. During the review of the wound care consultation report, it was revealed the consulting physician had documented an appointment had been made for a surgical consultation regarding surgical options for gangrenous left heel wound. In an interview with … | 2015-09-01 |
| 11178 | 11178 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2011-03-08 | 157 | D | 1 | 0 | 2ZE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, and staff interview, the facility failed to notify the legal representative one (1) of six (6) sampled residents after the resident sustained [REDACTED]. Resident identifier: #77. Facility census: 106. Findings include: a) Resident #77 Review of Resident #77's medical record revealed a Combined Medical Power of Attorney and Living Will document, dated 03/23/05, in which the resident designated a niece to serve as primary medical power of attorney representative (MPOA). In the event the niece was unable or unwilling to serve as a surrogate health care decision-maker, the resident designated a nephew to serve as the successor MPOA. Record review also revealed, on 09/13/06, the physician determined Resident #77 lacked the capacity to understand and make informed health care decisions. On this date, the MPOA document would have sprung into effect, with the resident's niece having the authority to make health care decisions on the resident's behalf. Review of the facility's records revealed an incident / accident report, dated 02/06/11, documenting that Resident #77 received a skin tear to the left upper arm measuring 1.5 cm x 0.5 cm. The resident's successor MPOA was notified of the skin tear at 1:00 p.m. that same day. There was no evidence in the resident's medical record to reflect the primary MPOA was unable or unwilling to serve; therefore, the primary MPOA (not the secondary MPOA) should have been notified of this injury. An interview with the director of nursing, on 03/09/10, confirmed staff notified the secondary MPOA, instead of the primary MPOA, of the resident's injury. | 2014-07-01 |
| 11396 | 11396 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 309 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as evidenced by the facility allowed an employee to provide care to a resident without a physician's directive. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report, dated 07/28/10, revealed a registered nurse (RN - Employee #111) went into resident's room to unhook intravenous access, and when she unhooked the intravenous access device, she realized that access had been obtained through a [MEDICAL TREATMENT] port-a-cath. Employee #111 stated she then unhooked the intravenous access device and flushed the [MEDICAL TREATMENT] port-a-cath. Review of the alleged abuse interview questionnaire, which was attached to the incident / accident report dated 07/28/10, revealed a statement from an unknown employee stating the oncoming RN found the antibiotic hanging and flushed the line (port-a-cath) with normal saline and [MEDICATION NAME] flush, and the physician was notified. Review of the nurses' notes, dated 07/28/10, revealed the physician was notified, but no directives from the physician to flush intravenous site (port-a-cath) were found. Review of the physician's orders [REDACTED]. On 11/03/10 at 3:00 p.m., an interview with the director of nursing (DON - Employee #106) revealed he agreed the port-a-cath should not have been flushed without a physician's orders [REDACTED]. . | 2014-03-01 |
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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 );