CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6078 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 154 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to fully inform residents who had been determined to possess the capacity to act as their own decision-maker, in a language that he or she could understand, of identified concerns regarding his or her total health status, including their cognitive status and psychosocial status as initiated in their individualized care plans. Residents were not informed of care plans established for behaviors. This was found for four (4) of four (4) residents who had voiced multiple documented complaints during 2013. Resident identifiers: #19, #62, #25, and #57. Facility census: 100. Findings include: a) Review of complaints, concerns, and abuse/neglect reporting began on 01/08/13 at 9:00 a.m. This review was continued and expanded on 01/20/14 as part of the extended survey protocol. 1) Resident #19 Review of the complaint/concern files identified this resident had thirty (30) documented concerns in 2013 to date. According to the documentation regarding these issues, the facility had attempted to resolve all of the resident's issues. The facility had not dismissed any of the resident ' s concerns as being unfounded or untrue. The high number of concerns filed by this resident prompted review of her medical record. This review the resident's physician had determined she possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score, as assessed on 12/17/13, was 15, indicating she was cognitively intact. She was acting as her own decision-maker. Review of her care plan, on 01/16/13 at 1:00 p.m., found she had a focus item for being at risk for changes in behavior problems related to making false accusations towards staff. The goal for this problem was (typed as written), Will remain free of behavioral disturbances daily thru next review. Interventions implemented toward meeting this goal were (typed as written): 1. Anticipate needs and provide care as able. 2. Provide emotional support as needed. Further review of the resident's medical record found there were no behaviors identified on the resident's minimum data set assessments. There was no evidence of any targeted behaviors being quantitatively monitored. There was no evidence of any behaviors, other than the frequency of her complaints. The record review found no basis for establishing the goal of (typed as written), Will remain free of behavioral disturbances daily thru next review. b) Following the review of Resident #19's medical record, patient liaison, Employee #176, was asked on 01/20/14 at 11:48 a.m., to provide a listing of residents who had voiced the most complaints and concerns in 2013. She provided the requested information a short time later, which indicated the following: 1) Resident #62 This resident had eleven (11) complaints/concerns/grievances documented. Resident #62 had been determined by a physician to possess the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 01/09/14 was 15, indicating she was cognitively intact. She was acting as her own decision-maker. She was currently president of the resident council. Review of her care plan, on 01/16/13 at 1:10 p.m., found she had a focus item for being at risk for behavior symptoms related to fabrications of staff refusing care/frequently making accusations toward staff and other residents. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Resident refuses psychiatric evaluation. 4. Use consistent approaches when giving care. 2) Resident #25 A review of the closed medical record for Resident #25 revealed she had been determined by a physician to possess the capacity to make informed medical decisions. This was verified in each of her care plan meeting minutes 07/24/13,08/08/13, and 10/16/13). She had scored 15/15 on the BIMS (Brief Interview for Mental Status) on 10/18/13. She was her own decision-maker during her stay at the facility. A review of the Concern Report files revealed Resident #25 had nine (9) grievances documented during her admission at the facility from 07/23/13 to 11/08/13. Review of the complaints and concerns found that the facility had attempted to resolve all of the issues. None had been dismissed as being unfounded or untrue. A review of her care plan, at 1:37 p.m. on 01/16/13, found she had a focus item for being noted to make false accusations towards staff related to [MEDICAL CONDITIONS]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Use consistent approaches when giving care. Medical record review found that although she had a care plan focus item related to being at risk for behaviors due to making false allegations or fabrications, there was no evidence of behaviors documented on the resident ' s comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. The only progress note in the entire record alluding to behaviors was the following on 10/18/13, which was the initiation date of the care plan for this focus, (typed as written) Nurse was standing outside of room passing medications when resident call light came on. Nurse finished passing pills that were already started. Nurse answered call light. Resident states, ' Its about time my call light has been on for an hour. ' Nurse explained to resident that she was standing outside of the room when the call light came on but I would be glad to assist her in repositioning. Resident states, ' You are just like everyone else, liars. ' Will continue to monitor. There was no entry in any of the physician's progress notes suggesting the presence of any behaviors. An interview was conducted with acting social services director, contracted Employee #44 on 1/21/14 at 11:50 a.m. She was identified by the Administrator, Employee #120 as the person responsible for facilitating resident care plan meetings. She was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. There was no evidence of behaviors being discussed in any of her care plan meeting minutes (07/24/13, 08/08/13, and 10/16/13) and her daughter had been in attendance at two (2) of the meetings. 3) Resident #57 This resident had eight (8) complaints/concerns/grievances documented. Resident #57 had experienced a recent significant change of condition and was determined by her physician to lack the capacity to make informed medical decisions on 12/27/13 due to illness/early dementia. Prior to that determination, she had acted as her own responsible party throughout her residency in 2013. Her Brief Interview for Mental Status (BIMS) score, as assessed on 11/27/13 was 15, indicating she was cognitively intact. Review of her care plan on 01/16/13 at 1:42 p.m. found she had a focus item for being at risk for behavior symptoms such as making false accusations towards staff and family related to mental illness and [MEDICAL CONDITION]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer meds per physician orders, observe for effectiveness and side effects such as but not limited to dizziness, drowsiness, and falls. 2. If resident exhibits inappropriate behaviors, speak in a soft, calm tone, attempt to redirect, and encourage resident to express herself in a more appropriate manner. 3. Observe for mental status/behavior changes when new medication started or with changes in dosage. 4. Use consistent approaches when giving care. c) Review found each of these residents had care plan focus items related to being at risk for behaviors due to making false allegations or fabrications, although none of them had evidence of behaviors documented on their comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. d) In an interview with the acting social services director, contracted Employee #44, on 01/21/14 at 11:50 a.m. (she was identified by administrator, Employee #120, as the person responsible for facilitating resident care plan meetings), she was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. It was then discussed that review had found those residents having the most complaints all had care plan focus items bringing their credibility into question. She was asked if the focus item related to making false allegations or fabrications had been discussed with these residents. She said they had not. | 2018-05-01 |
| 6079 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 155 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure four (4) of thirty-four (34) sample residents were afforded the right to formulate an advance directive. The facility failed to clarify and periodically review existing advance directives. Advance directives were not accurately documented to effectively communicate the resident's choices to the direct care staff should the need to implement, or not implement, cardiopulmonary resuscitation (CPR) arise. Resident identifiers: #114, #130, #99, and #5. Facility census: 100. Findings include: a) Resident #114 A medical record review was conducted on [DATE]. Resident #114 had a FULL CODE sticker on his condition alert tab in the chart. A green page in the chart stated Full Code. The monthly physician's orders [REDACTED]. (A full code would mean the facility would attempt to resuscitate the resident.) The resident's West Virginia Physician order [REDACTED]. The POST form was signed by the medical power of attorney on [DATE], and was signed by the physician on [DATE]. The information on the POST form was not transferred to the remainder of the medical record. b) Resident #130 Resident #130 was admitted to Hospice services on [DATE]. A copy of a physician's prescription on the medical record stated Please make patient DNR (do not resuscitate) dated [DATE]. This information was not updated in the medical record. His condition alert tab stated FULL CODE. A green page in the medical record stated Full Code. A sticker was placed on this page stating, Do Not Thin From Chart. A physician's orders [REDACTED]. No POST form was in the medical record. c) Resident #99 The condition alert tab in the medically record of Resident #99 did not address the code status of Resident #99. A Medical Power of Attorney, notarized [DATE], stated Do Not Resuscitate. The physician's orders [REDACTED]. No POST form was present. This medical record provided conflicting information in regards to the resident's choice of code status. d) Resident #5 A POST form, signed by the physician on [DATE], was marked Do Not Resuscitate. The physician's orders [REDACTED]. The condition alert tab, which was intended as a reference for staff, had a sticker stating FULL CODE. e) Staff interviews were held on [DATE] at 12:00 p.m. with the licensed nurses on duty. Employee #151, an agency Licensed Practical Nurse (LPN), stated she relied on the sticker on the Condition Alert tab as a reference in an emergent situation regarding the resident's condition Employee #69, LPN, stated she also referred to the sticker on the Condition Alert tab. Another LPN, Employee #110, stated she looked for a red or green paper in the chart to let her know the code status of a resident and compared it to the POST form. Employee #52, LPN, stated she looked on the Condition Alert tab and compared it to the POST form. The conflicting information found in the medical record and among staff members in regards to code status was discussed with the Administrator, Employee #120, and the Director of Care Delivery, Employee #124, Registered Nurse (RN) on [DATE] at 1:00 p.m. They acknowledged there was conflicting information in the residents' medical records. A policy, revised ,[DATE], was provided titled, Emergency Management code status identification. This policy stated, Review and documentation of new physician orders [REDACTED]. Employee #120 stated a new process was going to be put into place effective immediately due to the breakdown of the current system. | 2018-05-01 |
| 6080 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 166 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of snack-related forms provided by the dietitian, review of resident council minutes, resident interviews, and staff interviews, the facility failed to actively seek a resolution to grievances and/or to keep the resident informed of the progress being made. Residents had voiced reoccurring concerns regarding the availability and/or the variety of snacks available when the kitchen was closed; and/or the extended length of time required for care needs to be met for fifteen (15) of thirty (30) residents interviewed. Resident identifiers: #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, #141, #210 and #78. Facility census: 100. Findings include: a) Grievance: Snacks are not available and/or there was no variety of snacks when the kitchen was closed: 1) Resident #62 During an interview with Resident #62 at 3:30 p.m. on 01/07/14, during Stage 1 of the survey, she said there were few or no snacks kept on the care unit and if you requested something when the kitchen was not open you could not get it. She stated this was true for both food and/or drinks. The resident said she had stated this concern during resident council meetings, to the dietitian, at food club meetings, and to the nursing care staff, but nothing had been done. The only answer she received was from a nursing assistant, who said the kitchen would not stock snacks on the unit. 2) Resident #78 An interview with Resident #78 at 2:00 p.m. on 01/08/14, revealed she agreed there were few, if any, snacks available. She stated, If you want a snack they have to go to the kitchen to get it and you can't get anything when the kitchen is closed in the evening. She added, If you wanted something you should have the physician order [REDACTED]. According to the resident, there was usually juice or tea and crackers kept on the unit, but nothing more. She added that this had been brought up at resident council and she had voiced it to nursing staff and the kitchen staff, but she was told there was nothing they could do. 3) As a result of these interviews, the following observations were made during the survey: Observations of the nourishment kitchen serving the 300/400 halls were made at 8:30 a.m. on 01/08/14; 9:30 a.m. on 01/09/14; 3:00 p.m. on 01/13/14; and 8:15 a.m. on 01/14/14 (on 01/14/14 Employee #87 (Maintenance Director) was present). On each of these observations, there were only graham crackers, soda crackers, and individual containers of peanut butter and jelly found. The refrigerator contained orange juice and a large container of tea. There were never more than four (4) individual containers of milk. There was ice cream in the freezer, but no fruit, puddings, cookies, or bread. 4) Observations of the nourishment kitchen serving the 100/200 halls were made at 8:45 a.m. on 1/08/14; 2:00 p.m. on 01/09/14; and 8:15 a.m. on 01/14/14. The only snack items available were graham crackers, soda crackers, and individual containers of jelly and peanut butter. On 01/14/14, there was a partial loaf of bread. The refrigerator contained large containers of sweetened iced tea and orange juice and ice cream. There were no puddings, cookies, or fruits. There was no milk on 01/08/14 or 01/09/14 and only four (4) individual containers of milk on 01/14/14. 5) All observations revealed multiple individual containers of ordered supplements labeled for certain residents. There were also cans of soda, provided by purchasing. 6) At 9:30 a.m. on 01/14/14, following the earlier observation at 8:15 a.m., both nourishment kitchens were stocked with at least a dozen individual containers of milk, 3 cans of soup, bread, 4 puddings, and a 2 covered bowls of canned fruit. Employee #18 (Aide), who was present, stated this was . a lot more than we usually have. They continued to be stocked throughout the remainder of the survey. 7) An additional six (6) resident interviews were completed during Stage 2 of the survey at 8:30 a.m. on 01/16/14. The residents were asked, Can you get a snack in the evening? and What would you like to get?. The responses were: 1) Resident #64: . no snacks unless the kitchen sends them. When asked what she would like to have she said Maybe a sandwich or toast. 2) Resident #15: You get drinks for snacks if you ask for one. He said he would like food. 3) Resident #133: No snacks. The resident said he would like A sandwich. 4) Resident #115: They don't bring snacks. They tell you, 'no extra.' She said she prefers fruit or cookies and milk. 5) Resident #58: They don't keep anything but crackers. She said she would like anything but crackers. 6) Resident #210: You only get a snack if you're a diabetic. The resident said cookies would be nice. All of these residents stated they had questioned the staff about snacks, but it had not resulted in them being provided. Some said they just get their family to bring things in. None of the residents had been told why their requests had not been met. 8) During an interview with Employee #109 (Activity Director), at 10:30 a.m. on 01/08/14, she was asked to explain some of the items on the Resident Council Minutes form as she attended the meetings. One of the items listed under, Compliments, comments, on 08/15/13, was Snack machine items - Would like switched but they state they cannot change them. She explained that the residents used the snack machine a lot and when asked, added that the residents say there are not a lot of snacks on the floor in the evening. She stated she had forwarded these complaints to the dietary supervisor and administration. She was not aware of any action taken. In an interview with the Registered Dietitians, at 11:35 a.m. on 01/08/14, they acknowledged awareness of the lack of snacks stocked in the nourishment kitchens and stated they had no control over this as the food supplies were provided by contract with a contracted company. The dietitian who did the assessments said, when interviewing residents, she asked them if they wanted a snack and what their preferences were. She then added it to their food order and had the kitchen send them out, but she stated she only did this for the residents who wanted a snack on a daily basis. The Senior Dietitian stated the nourishment kitchens were stocked daily in the afternoon by the kitchen from a written request from the unit nurse and signed for by a nurse when received. She also stated the aides sign out snacks when they are taken from the room and provided a copy of the Nourishment Room Snack Sign Out Log for January 2013. 9) During an observation of the nourishment kitchens at 1:00 p.m. on 01/08/14, the sign out logs were absent. Employees #98, #7, and #142 (aides) stated they were not required to sign out items from the nourishment kitchen. Employees #116 and #106 (Nurses) verified there was no sign out form in use. Employee #116 stated there had been such a form but the practice had only been in effect for about a month and was dropped. 10) The Senior Dietitian provided an order for [REDACTED]. Of the four (4) types of milk, only a few containers of 2% milk were observed. 11) During an interview with Employee #15 (Food Service Supervisor), at 9:00 a.m. on 01/09/14, she acknowledged the use of the sign-out form for snacks but agreed it had not been used. for a long time. She stated the kitchen did not provide soft drinks, except for ginger ale for therapeutic use. She admitted awareness of complaints from time to time from the residents about snacks, but stated there was nothing she could do about it and did not explain. She provided a copy of the HCR ManorCare HS Snack Rotation schedule which listed puddings, cookies, ice cream, peanut butter crackers, pretzels,cheese its, and graham crackers. 12) An evening visit at 11:30 p.m. on 01/14/14, revealed the same snack items (and same amount) present in the nourishment kitchens as on the earlier visit on the same day (9:30 a.m.). Interviews with Employees #28, #37, #164, #32, and #20 (aides) revealed they had delivered the labeled HS (bedtime) snacks, but had not offered any additional snacks and none had been requested by residents. They expressed surprise at the amount of snacks available and stated that there was usually only Jugs of tea and a juice, and crackers. Employees #32 and #20 stated Resident #29, who was yelling out at that time, could be calmed at times by getting her up and giving her a sandwich, but there was never anything to fix a sandwich with. All of them agreed with this and all agreed a sandwich or toast was the most requested snack. The aides reviewed the HS (hour of sleep) Snack list and said it appeared accurate, but all stated, except for graham crackers and ice cream, none of these items were stocked in the nourishment kitchens. 13) During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor) at 12:50 p.m. on 01/14/14, Employee #15 was asked if she had met with the residents to listen to their concerns/requests regarding snacks. She stated a Food Committee met periodically to discuss issues with the food and she attended these meetings, but she had no authority to promise them snacks. She stated she had forwarded the residents' requests to Administration in the past. 14) In an interview with the Administrator, at 8:30 a.m. on 1/24/14, she acknowledged that she was aware of the residents' concerns about the poor amounts and/or variety of snacks available on the units. She could not show any evidence they had discussed or attempted to alleviate the concerns; or had informed the residents of any plans to do so. b) Grievance: The length of time required before the residents' personal needs are met is too long. Twelve (12) of the twenty-seven (27) residents in the Stage 1 sample, who were deemed interviewable by the facility, stated the caregivers were slow to answer their lights and/or to provide assistance promptly. 1) Resident #115 This resident stated the aide would respond to the light, but say, Wait a minute. and not return for a long time. 2) Residents #62 #133, #19, and #141 These residents were re-interviewed in Stage 2 of the survey. They were asked if they had ever complained about the slow provision of care, and what the results of the complaints were. Each of the residents stated they attended Resident Council. they said the slow answering of lights was frequently expressed during the meetings. A review of the minutes from the previous six (6) months revealed concerns addressed about slow response to needs in five (5) of the six (6) months. The September 2013 and October 2013 minutes indicated the call light problem was . a little bit better, but in November 2013, there were again complaints registered. None of the residents interviewed could state what the facility had done to try to solve this problem. 3) Resident #62 This resident was the resident council president. During an interview at 3:30 p.m. on 01/07/14, she stated she depended on the Regional Ombudsman to tell her what was being done about the concerns made by the residents. She added she did not feel the facility was understaffed. The resident said from her room, which was adjacent to the nurses' station, she could hear the aides talking. She said she heard them say such things as, . not me this time and I'm not going in there again. 4) Residents #64, #7, #70, #15, #115, #84, #88, #58, and #65 These residents were interviewed at 10:00 a.m. on 01/16/14. All had complaints about slow response to care needs and all stated they had reported these complaints to staff. None of them could offer any action taken by the facility to resolve this concern, nor had any of them been offered an explanation of what was being done. 5) During an interview with Employee #109 (Activities Director), at 10:30 a.m. on 01/08/14, she acknowledged she attended all resident council meetings and verified there were usually complaints from the residents about staff being slow to respond to lights. She said these concerns were always relayed to administration via the social worker or director of nurses. She admitted that she did not remember anyone coming to resident council to discuss the concern with them. She was not aware of what action may have been done. 6) Employee #122, a social worker, was interviewed at 2:00 p.m. on 01/13/14. She admitted she was aware of the residents' complaints that their lights were slow in being answered. She was not sure what action was planned or if the concern was taken to Quality Assurance Committee. 7) During an interview with the Administrator, a social worker (Employee #175) and the Director of Nursing, and the survey team, at 11:20 a.m. on 01/15/14, they acknowledged awareness of complaints related to the slow answering of lights, but stated action was taken whenever a complaint was made. The minutes of the council meetings were reviewed. The Administrator confirmed there was very little evidence which described what follow-up was done following a complaint. The Administrator assured the group that staffing was adequate. This was verified during the survey. No additional information to validate any response presented to residents individually or to the resident council was provided prior to exit of the facility. | 2018-05-01 |
| 6081 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 225 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of complaint files, review of incident reports, review of personnel files, and staff interview, the facility failed to ensure all allegations of mistreatment, neglect, injury of unknown origin, or abuse were reported immediately to the appropriate State agencies in accordance with this regulation and with Code of State Rules, Title 64 Series 13 - Nursing Home Licensure Rule for West Virginia. The facility also failed have evidence all allegations were thoroughly investigated. This was found for seven (7) of forty-three (43) documented grievances/concerns reviewed. Additionally, the facility had not ensured it did not employee individuals who had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. Thirteen (13) of twenty (20) personal files reviewed did not have this information. These issues had the potential to affect all residents. Employee identifiers: #49, #15, #122, #119, #177, #178, #179, #180, #181, #182, #183, #184, and #187. Resident identifiers: #50, #148, #111, #47, #27, #71, and #25. Facility census: 100. Findings include: a) Resident #50 A review of a Concern Form revealed the son of Resident #50 made the following allegations during the course of a care plan meeting attended by both the resident and his son on 01/09/14: 1. Resident #50's trash can and/or phone were frequently not within the reach of the resident. 2. The resident was receiving poor nail care. 3. Resident #50 stated he gets poor response time to his call light. A written report was completed for each of these allegations on 01/09/14. The concerns were assigned to Employee #116 (RN and Director of Care Delivery) on 01/10/14, to be resolved by 01/15/14. Notices were distributed to All nursing staff in service on 01/10/14, instructing corrective action to be taken regarding the allegations and the following Resolution of Concern was written on the forms and signed by Nurse #116 - At this time, resident et (and) family are satisfied (sign for 'with') actions taken by facility to correct these concerns. Will cont. (continue) ongoing communication (sign for 'with') resident et family to ensure concerns are resolved. There was no evidence the allegations of neglect were reported to the appropriate State agencies as required, nor was there evidence the allegations were thoroughly investigated. b) Resident #148 Review of a facility Concern Form revealed Resident #148 had voiced a complaint to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose were on at that time. The resident told the therapist they had been left on for two (2) days and nights, when they were supposed to be taken off at night. He also stated he had asked someone to take them off and they said they would, but did not. An incident report was also filed and the resident's physician was informed. The form was signed by Employee #77 (Director of Nursing), but no one was assigned to take action on this concern. There was a partially completed State Report attached to the Concern form, but there was no evidence the resident's allegation of neglect was either reported to the appropriate State agencies, or that any type of investigation had been made. There was no indication the facility staff had notified the resident of any action taken to ensure this did not reoccur. c) Resident #111 A concern form, reviewed, at 10:00 a.m. on 01/14/14, included Resident (#111) found in bed (sign for 'with') wet sheet, dried brown urine circled on sheets. Resident's hair even saturated (sign for 'with') urine. Resident was cold, wet and shivering. The date on the form was 12/20/13 at 8:30 a.m., but it did not state who found the resident in that condition. A nurse (no longer at the facility) was assigned the concern for resolution on 12/21/13. There was no other indication of her involvement. A nurse, Employee #124, completed an incident report on 12/20/13, which noted the family was notified. Employee #77 (Director of Nursing) documented Interviewed LN & CNAS (licensed nurse and certified nursing assistants) caring for resident during shift prior to reported concern. Care provided prior to end of shift and Investigation completed. Care determined to be provided. The completion date on the form was 12/22/13. There was no attached evidence of an investigation. There was no evidence this occurrence was recognized as an allegation of neglect and reported to the appropriate State agencies. When questioned about the incident, at 11:15 a.m. on 01/14/14, Employee #77 confirmed there was no additional information filed, although she did say she talked to the nurse who was working at the time of the incident. d) Resident #47 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, found a concern form for this resident noted, Resident voiced that she has not been receiving CPM (continuous passive motion) machine (ordered therapy). The resident reported this to Employee #79 (Occupational Therapist) on 12/22/13, who filed the concern form. This allegation of neglect was not reported to the appropriate State agencies and a thorough investigation was not completed. Employee #116 (nurse) was assigned to take action on the concern. The record indicated his determination that the therapy had not been completed on 12/19/14, and Employee #88 (LPN) had confirmed this in a signed statement. Employee #116 indicated he had discovered four (4) missed treatments between 12/19/13 and 12/22/13 and stated in the report that the resident had confirmed the missed treatments. There were no other interviews or information collected. The resolution was education for the staff nurse identified for the single omission on 12/19/14. During an interview with Employee #116 at 1:00 p.m. on 01/14/14, he stated it was given to him as a concern only and he assumed the decision about reporting had already been made. e) Resident #27 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, revealed a concern reported to Employee #88 (LPN Supervisor) on 12/23/13, by Resident #27. Resident #27 stated Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. She did not want care from that aide again. The facility did not recognize this as allegations of neglect and did not report the allegations to the appropriate State agencies. The investigation contained only a follow-up interview with Resident #27 and interviews with three (3) other residents. One (Resident #141) had the same complaint about the same aide. f) Resident #71 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed staff reported a skin tear to the right knee and a large bruise on the left lower back of Resident #71 when he was bathed at 12:30 p.m. on 12/03/13. The resident denied any falls and staff documented, Unsure as to exact cause. The facility did not report this bruise of unknown origin to the appropriate State agencies and there was no investigation. There was an entry which stated, Res (resident) did sit down hard in w/c (wheelchair) one day last week when he almost missed the chair. At the time of discovery, no description of the bruise was documented to assist in determining the age of the bruise and no evidence that staff interviews had been done. g) Resident #25 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed the daughter of Resident #25 had reported a concern to Employee #88 (LPN Supervisor) on Monday, 10/14/13. The daughter visited on Sunday evening (10/13/13) and Resident #25 was wearing the same clothes she was dressed in on Saturday morning (10/12/13) and had no water. The cup in her room was labeled from the 11-7 shift on Saturday night. The facility did not report these concerns as allegations of neglect. There was no evidence of any investigation. e) The Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation and the policies regarding grievances/complaints at 10:00 a.m. on 01/14/14. She responded at 8:50 a.m. on 01/15/14 with the Patient Protection Practice Guide which stated in its opening paragraph, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. She was asked if there was a policy instructing staff of who and how to report to in this facility. At 10:50 a.m. on 01/15/14, she provided a one page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following and contained a list of agencies. She stated that she was the person ultimately responsible for reporting. The Administrator also provided a one-page instruction sheet, which accompanied the use of the concern form in use and a decision tree. She acknowledged that the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. The Administrator stated there was no evidence to show that the facility's review and/or acceptance of these documents and she could locate no facility distinct policies. An interview with the Administrator, Employee #175 (Social Worker), and Employee #77 (Director of Nursing), along with the survey team, was conducted at 11:20 a.m. on 01/15/14, to review the above Concern Forms. The facility provided no additional evidence regarding these occurrences as of the time of exit. The administrator acknowledged that the lack of individualized policies to follow might have resulted in the allegations not being reported. g) Review of personnel files found the facility had not ensured thorough background checks and/or abuse registry checks had been conducted for all employees. These findings were verified on 01/13/14 at 11:00 a.m. by Employee #40, the human resource manager. The following issues were found: 1) Employee #49 The facility had no evidence of statewide criminal background check had been completed for this nurse aide. 2) Employee #15 The facility did not have evidence the abuse registry had been checked for this dietary employee. 3) Employee #122 There was no evidence the abuse registry had been checked for this social worker. 4) Employee #119 No evidence of a statewide criminal background check was found in this housekeeper's file. 5) Employee #187 There was no evidence this nurse had had a statewide criminal background check. h) On 01/21/14 at 1:30 p.m., it was discovered that contracted dietary employees were not included on the employee list. A list of contracted dietary employees was requested. Review of the eight (8) files for these staff found none of them had verification that they did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was confirmed by administrator, Employee #120 on 01/21/14 at 2:00 p.m. These contracted employees were #177, #178, #179, #180, #181, #182, #183, #184, and #187 (a Registered nurse, 2 Cooks, and 6 Dietary Aides) | 2018-05-01 |
| 6082 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 226 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, personnel file review, and policy review, the facility failed to develop facility specific policies and procedures regarding identification, investigation and reporting of allegations of resident mistreatment, neglect, abuse and misappropriation of resident property. The facility had no facility specific written policies and procedures which included procedures for investigating different types of incidents, identifying the staff member responsible for the initial reporting, reporting of results to the proper authorities, and identifying what constituted an allegation of abuse, neglect, or mistreatment of [REDACTED]. This was found for thirteen (13) of twenty-one (21) employees reviewed (Employees #119, #49, #15, #122, #177, #178, #179, #180, #181, #182, #183, #184, and #187). The residents affected included Residents #50, #148, #111, #47, #27, #71, and #25; however, the practice had the potential to affect all residents. Facility census: 100. Findings include: a) During the survey, seven (7), of forty-three (43) Concern Reports reviewed, which should have been reported to the appropriate State agencies as allegations of neglect or mistreatment of [REDACTED]. In addition, the facility failed to thoroughly investigate the allegations. Affected residents were Residents #50, #148, #111, #47, #27, #71, and #25. Below are the allegations which were not addressed as required: 1) Resident #50 During a care plan meeting on 01/09/14, attended by the resident and a family member, the following allegations of neglect were made: -- The resident's trash can and/or phone were frequently not within reach of the resident. -- The resident was receiving poor nail care. -- The resident stated he gets poor response time to his call light. 2) Resident #148 Resident #148 voiced a complaint of neglect to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose were on at that time. The resident told the therapist they had been left on for two (2) days and nights, when they were supposed to be taken off at night. He also stated he had asked someone to take them off and they said they would, but did not. 3) Resident #111 A concern form regarding neglect was, Resident (#111) found in bed (sign for 'with') wet sheet, dried brown urine circled on sheets. Resident's hair even saturated (sign for 'with') urine. Resident was cold, wet and shivering. 4) Resident #47 A concern form regarding neglect for this resident noted, Resident voiced that she has not been receiving CPM (continuous passive motion) machine (ordered therapy). The resident reported this to Employee #79 (Occupational Therapist) on 12/22/13, who filed the concern form. 5) Resident #27 On 12/23/13, the resident reported neglect to Employee #88 (LPN Supervisor). The resident said Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. The resident said she did not want care from that aide again. 6) Resident #71 An injury of unknown origin was reported to staff regarding a skin tear to the right knee and a large bruise on the left lower back of Resident #71 when he was bathed at 12:30 p.m. on 12/03/13. The resident denied any falls and staff documented, Unsure as to exact cause. 7) Resident #25 The family of Resident #25 reported a concern of neglect to Employee #88 (LPN Supervisor) on Monday, 10/14/13. The family visited on Sunday evening (10/13/13) and Resident #25 was wearing the same clothes she was dressed in on Saturday morning (10/12/13). The concern also alleged the resident had no water on Sunday evening. The cup in the resident's room was labeled as provided on the 11-7 shift on Saturday night. 8) Various employees handled the concerns. Employee #116 (RN) had handled several of the concerns. During an interview at 1:00 p.m. on 01/14/14, he stated he assumed the decision had regarding reporting had already been made when he was given the concern to resolve. When asked who was responsible for reporting allegations to the State, his response was Social Services. During an interview with Employee #57 (LPN - Supervisor), at 11:50 p.m. on 01/14/14, she was asked to whom she reported concerns/allegations from the residents. She said she reported them to the director of nurses or the oncoming supervisor. She did not know who reported them to the State. In an interview with Employee #122 (Social Worker), at 09:45 a.m. on 01/14/14, she was asked who was responsible for reporting allegations of abuse/neglect to the State. Her answer was Employee #175 (Social Worker) who was the Patient Advocate. 9 Due to the confusion displayed by front-line employees, at 10:00 a.m. on 01/14/14, the Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation of resident property. She was also asked to provide the policies regarding grievances/complaints. The administrator responded at 8:50 a.m. on 01/15/14, with a commercially printed excerpt entitled: Patient Protection Practice Guide. Its opening paragraph stated, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. The guide contained no procedures individualized to the facility. When asked if there was a facility policy which specifically instructed staff to whom and how to report allegations, the administrator stated, I don't think so. At that time, the administrator said she was the person ultimately responsible for reporting. At 10:50 a.m. on 01/15/14, the administrator provided a one (1) page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following. The paper contained a list of agencies. The Administrator also provided a one-page instruction sheet which accompanied a decision tree relative to the use of the concern form. She acknowledged the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. On 01/15/14 at 10:50 a.m., the Administrator stated there was no evidence to show the facility's review and/or acceptance of these documents. She also stated she was unable to locate facility specific policies. The Administrator said she had called an ad hoc Quality Assurance meeting to address the discovery that the facility had no abuse/neglect policy. An interview was conducted with the Administrator, the Social Worker (Employee #175) and the Director of Nursing (Employee #77) At 11:20 a.m. on 01/15/14. All members of the survey team were present. The concerns which should have been reported and investigated, but were not were discussed. The facility was unable to provide additional evidence for these allegations of neglect. The administrator acknowledged the lack of individualized facility policies might have resulted in the allegations not being reported. b) Employees #119 and #49 Ten (10) personnel files were reviewed on 1/13/14 at 10:00 a.m. The review found the facility failed to obtain statewide criminal background checks for two (2) of the ten (10) records reviewed. This was found for Employee #119 (Housekeeping) and Employee #49 (Nurse Aide). c) Employees #15 and #122 The facility also failed to verify that two (2) prospective employees and eight (8) contracted staff did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was found for Employee #15 (Nurse Aide) and Employee #122 (Social Worker). During an interview with human resources director, Employee #40 on 01/13/13 at 11:00 a.m., she confirmed the facility failed to screen all potential employees for statewide criminal background or a history of abuse, neglect or mistreating residents as required. d) Contracted Employees #177, #178, #179, #180, #181, #182, #183, #184, and #187 (a Registered nurse, 2 Cooks, and 6 Dietary Aides) On 1/21/14 at 1:30 p.m., it was discovered that contracted dietary employees were not included on the employee list. A list of contracted dietary employees was requested. Review of the eight (8) files for these staff found none of them had verification that they did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was confirmed by administrator, Employee #120 on 01/21/14 at 2:00 p.m. On the morning of 01/23/14, it was found there were once again additional agency staff working in the building. Information was requested on these three (3) nurses. On 01/23/14 at 1:58 p.m., human resources director, Employee #40 confirmed that for a registered nurse, Employee #187, the facility had no documentation of current license, state wide criminal background check, or verification that she did not have findings of abuse, neglect, or misappropriation of funds prior to allowing her to have contact with residents. | 2018-05-01 |
| 6083 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 242 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of snack-related forms provided by the dietitian, review of resident council minutes, resident interviews, and staff interviews, the facility failed to ensure eight (8) of thirty (30) residents interviewed were afforded the right to make choices about aspects of their lives in the facility, which were significant to the residents. Residents voiced reoccurring unresolved concerns regarding the availability and/or the variety of snacks available when the kitchen was closed. Affected residents included Residents #62, #64, #15, #133, #115, #58, #210, and #78; however, the practice had the potential to affect more than an isolated number of other residents. Facility census: 100. Findings include: a) Resident #62 In Stage 1 of the survey, during an interview with Resident #62, at 3:30 p.m. on 01/07/14, she said there were few or no snacks kept on the care unit and if you requested something when the kitchen was not open, you could not get it. She stated this was true for both food and/or drinks. The resident said she had stated this concern during resident council meetings, to the dietitian, at food club meetings, and to the nursing care staff, but nothing had been done. The only answer she had received was from the aide who said the kitchen would not stock snacks on the unit. b) Resident #78 An interview with Resident #78, at 2:00 p.m. on 01/08/14, revealed she agreed there were few, if any, snacks available. She stated, If you want a snack they have to go to the kitchen to get it and you can't get anything when the kitchen is closed in the evening. She added, If you wanted something you should have the physician order [REDACTED]. According to the resident, there was usually juice or tea and crackers kept on the unit, but nothing more. She added that this had been brought up at resident council and she had voiced it to nursing staff and the kitchen staff, but she was told there was nothing they could do. c) Observations of the nourishment kitchen serving the 300/400 halls were made at 8:30 a.m. on 01/08/14; 9:30 a.m. on 01/09/14; 3:00 p.m. on 01/13/14; and 8:15 a.m. on 01/14/14 (on 01/14/14 Employee #87 (Maintenance Director) was present). On each of these observations, there were only graham crackers, soda crackers, and individual containers of peanut butter and jelly found. The refrigerator contained orange juice and a large container of tea. There were never more than four (4) individual containers of milk. There was ice cream in the freezer, but no fruit, puddings, cookies, or bread. d) Observations of the nourishment kitchen serving the 100/200 halls were made at 8:45 a.m. on 1/08/14; 2:00 p.m. on 01/09/14; and 8:15 a.m. on 01/14/14. The only snack items available were graham crackers, soda crackers, and individual containers of jelly and peanut butter. On 01/14/14, there was a partial loaf of bread. The refrigerator contained large containers of sweetened iced tea and orange juice and ice cream. There were no puddings, cookies, or fruits. There was no milk on 01/08/14 or 01/09/14 and only four (4) individual containers of milk on 01/14/14. e) All observations revealed multiple individual containers of ordered supplements labeled for certain residents. There were also cans of soda, provided by purchasing. f) At 9:30 a.m. on 01/14/14, following the earlier observation at 8:15 a.m., both nourishment kitchens were stocked with at least a dozen individual containers of milk, 3 cans of soup, bread, 4 puddings, and a 2 covered bowls of canned fruit. Employee #18 (Aide), who was present, stated this was . a lot more than we usually have. They continued to be stocked throughout the remainder of the survey. g) An additional six (6) resident interviews were completed during Stage 2 of the survey at 8:30 a.m. on 01/16/14. The residents were asked, Can you get a snack in the evening? and What would you like to get?. The responses were: 1) Resident #64: . no snacks unless the kitchen sends them. When asked what she would like to have she said Maybe a sandwich or toast. 2) Resident #15: You get drinks for snacks if you ask for one. He said he would like food. 3) Resident #133: No snacks. The resident said he would like A sandwich. 4) Resident #115: They don't bring snacks. They tell you, 'no extra.' She said she prefers fruit or cookies and milk. 5) Resident #58: They don't keep anything but crackers. She said she would like anything but crackers. 6) Resident #210: You only get a snack if you're a diabetic. The resident said cookies would be nice. All of these residents stated they had questioned staff about snacks, but it had not resulted in them being provided. Some said they just get their family to bring things in. None of the residents had been told why their requests had not been met. h) During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor) at 12:50 p.m. on 01/14/14, Employee #15 was asked if she had met with the residents to listen to their concerns/requests regarding snacks. She stated a Food Committee met periodically to discuss issues with the food and she attended these meetings, but she had no authority to promise them snacks. She stated she had forwarded the residents' requests to Administration in the past. i) In an interview with the Administrator, at 8:30 a.m. on 1/24/14, she acknowledged that she was aware of the residents' concerns about the poor amounts and/or variety of snacks available on the units. She could not show any evidence they had discussed or attempted to alleviate the concerns; or had informed the residents of any plans to do so. | 2018-05-01 |
| 6084 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 244 | E | 0 | 1 | ZW4411 | Based on resident interviews, staff interviews, and review of resident council meeting minutes, the facility failed to act upon the grievances and recommendations of the resident council in a timely manner. In addition, the facility failed to communicate its decisions to the group. An example was the facility's failure to respond to repeated complaints of slow response by staff to call lights. This had the potential to affect all resident council members, as well as all residents who used call lights to summon assistance. Facility census: 100. Findings include: a) Residents #62, #133, #19, #141, and #78 In interviews, these residents stated they attended Resident Council Meetings. According to the residents, during the meetings, they frequently expressed complaints about the slow answering of call lights. A review of the council meeting minutes from the previous six (6) months revealed concerns addressed about slow response to needs in five (5) of the six (6) months reviewed. In September 2013 and October 2013, the minutes indicated the call light problem was . a little bit better. However, in November 2013, there were again complaints registered. None of the residents interviewed could state what the facility had done to try to solve this problem. b) Resident #62 In an interview with Resident #62, the Resident Council President, at 3:30 p.m. on 01/07/14, she stated the residents at council complained almost every meeting about the staff taking too long to respond to their needs. She added she did not feel the facility was understaffed. The resident said from her room, which was adjacent to the nurses' station, she could hear the aides talking. She said she heard them say such things as, . not me this time and I'm not going in there again. She said she had said this during a council meeting, but did not know if it had been passed on. She said she thought Employee #109 (Activities Director) filled out a separate form and gave it to the social worker and Employee #109 reviewed the complaints at the next meeting. She did not recall anyone talking to the council about the slow response. She said she depended on the Regional Ombudsman to tell her what was being done about the concerns made by the residents. c) During an interview with Employee #109 (Activities Director), at 10:30 a.m. on 01/08/14, she acknowledged she attended all resident council meetings and verified there were usually complaints from the residents about staff being slow to respond to lights. She said these concerns were always relayed to administration via the social worker or director of nurses. She admitted that she did not remember anyone coming to resident council to discuss the concerns with the residents. Employee #109 was not aware of what actions may have been taken. d) Employee #122 (Social Worker) was interviewed at 2:00 p.m. on 01/13/14. She acknowledged she was aware of the residents' complaints that their lights were slow in being answered. She was not sure what action was planned, or if the concern was taken to the Quality Assurance Committee. e) During an interview with the Administrator, Employee #175 (Social Worker), and Employee #77 (Director of Nursing), along with all the survey team, at 11:20 a.m. on 01/15/14, they acknowledged awareness of complaints related to the slow answering of lights and stated action was taken whenever a complaint was made. The Administrator reviewed the minutes of the council meetings and verified there was very little documentation to describe what follow-up was done following a complaint. No additional information to validate any response presented to residents individually or to the resident council was provided prior to exit of the facility. | 2018-05-01 |
| 6085 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 247 | E | 0 | 1 | ZW4411 | Based upon resident interview, staff interview, policy review, and record review, the facility had no evidence that notice was given before the resident's room or roommate in the facility was changed. This was found for one (1) of 35 residents reviewed in the Quality Indicator Survey sample, and for three (3) randomly reviewed residents who had room changes in December 2013 or January 2014. Resident identifiers: #58, #109, #148, and #141. Facility census: 100. Findings include: a) Review of facility's policy and procedure for room change notification was on 01/13/14 at 3:00 p.m. The Social Services manual stated Notify patients and responsible parties, as directed, about changes such as room or roommate changes. and Notify the patient or responsible responsible party of the change, the reason for the change, and respond to questions. b) The Social worker (agency), Employee #44, was interviewed on 01/14/14 at 12:19 p.m. She said that social workers do notifications of room/roommate changes when they are aware of them, but the notifications were also done by admissions and by nursing. She was asked where the notification would be documented. She said that social workers document the notification as a progress note in the electronic medical record. She felt that admissions and nursing probably did so as well, but could not say for sure. The Administrator, Employee #120, was interviewed on 01/14/14 at 12:40 p.m. She said she thought there was a form designed for documentation of room/roommate change notification. She was asked to provide a list of room/roommate changes for the past two (2) months. c) The list was provided on 01/14/13 at 1:40 p.m. The Administrator said that although notice of room/roommate changes may have been provided, admissions staff and/or nursing were not always documenting that notice was given. d) Resident #58 said during an interview on 01/07/14 at 10:23 a.m., that she was never notified of a room change in October 2013. Review of the records found no evidence that any notice was ever given. e) Random review of other room changes in December 2013 and January 2014 for residents found the following: 1) Resident #109 was moved on 12/18/14. There was no evidence of notice prior to the move. 2) Resident #148 was moved on 12/04/13. There was no evidence of notice prior to the move. 3) Resident #141 was moved on 12/21/13. There was no evidence of notice prior to the move. | 2018-05-01 |
| 6086 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 272 | D | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of the comprehensive assessments for two (2) of thirty-four (34) Stage 2 sample residents. The minimum data set (MDS) assessments completed during Resident #74's stay in the facility did not identify the resident had a pacemaker. Resident #52's urinary continence status was coded incorrectly on the MDS. Resident identifiers: #74 and #52. Facility Census: 100. Findings include: a) Resident #74 Review of this resident's medical record, on 01/14/14 included a review of the admission history and physical, completed by the Medical Director, Employee #102 on 07/18/13. The physician noted under Past Surgical History, the resident had a pacemaker. The cumulative [DIAGNOSES REDACTED]. At no time did the nursing progress notes describe the resident as having a pacemaker throughout his stay at the facility. Both Physical therapy and Occupational therapy notes, dated 10/03/13 and 10/14/13 (a total of four forms), listed pacemaker under the precautions area on the form. The Medical Directory had signed these forms. A review of the Minimum Data Sets (MDS) for Resident #74, along with the Resident Assessment Coordinator, Employee #99, found none of the resident's assessment identified the resident's pacemaker. The MDS Section for Active Diagnoses, I8000, did not have an ICD-9 Code entered to indicate the resident had a pacemaker. Review of the resident's care plan found it did not the resident's pacemaker. In a discussion with the Administrator, Employee #120, on 01/14/14 at 2:00 p.m., she agreed it was problematic. b) Resident #52 A review of the medical record revealed this [AGE] year-old male was admitted to the facility on [DATE]. The resident's admitting [DIAGNOSES REDACTED]. The resident's comprehensive assessment (MDS) on admission indicated he was occasionally incontinent (less than 7 episodes) of urine. The 30 day MDS, with an assessment reference date (ARD) of 09/02/13, indicated he was always continent of urine. The MDS, with an ARD of 10/31/13, indicated he was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). A review of the progress notes for the assessment period of the quarterly MDS revealed on 10/23/13, 10/24/13, 10/26/13, 10/27/13, 10/2813, and 10/31/13, the nursing staff had documented Resident #52 was continent of bowel and bladder. During an interview, at 11:15 a.m. on 01/14/14, Employee #116 (RN), stated Resident #52 was not incontinent. The nurse reviewed the previous 30 days of task - aide documentation on the electronic medical record and only two (2) incidents of incontinence were entered. The nurse stated the resident was even independent with his toileting. During an interview with Employees #55 and #99 (MDS nurses), at 12:00 noon on 01/14/14, they acknowledged, after reviewing the record, that quarterly MDS was marked in error and should have been marked as 0 as the resident was not incontinent. | 2018-05-01 |
| 6087 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 278 | D | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the assessments for (2) of thirty-four (34) Stage 2 sample residents did not accurately reflect the residents' status. Resident #74's MDS did not identify the resident had a pacemaker. The MDS for Resident #52 did not accurately reflect the resident's continence status. Resident identifiers: #74 and #52. Facility Census: 100 Findings include: a) Resident 74 Medical record review, on 01/14/14, noted the Medical Director had documented the resident had a pacemaker on the resident's admission history and physical which was completed on 07/18/13. The [DIAGNOSES REDACTED]. Nursing progress notes did not describe the resident had a pacemaker throughout his stay at the facility. Both Physical therapy and Occupational therapy notes, dated 10/03/13 and 10/14/13, (a total of four (4) forms) listed pacemaker under the precautions area on the form. Review of the resident's MDS with the Resident Assessment Coordinator, Employee #99, found none of the MDS assessments completed during the resident's stay identified the resident had a pacemaker. In an interview with the Administrator, Employee 120, on 01/14/14 at 2:00 p.m., she agreed it was problematic. b) Resident #52 A review of the medical record revealed this [AGE] year-old male was admitted to the facility on [DATE]. The resident's admission MDS indicated he was occasionally incontinent (less than 7 episodes) of urine. The 30 day MDS, with an assessment reference date of 09/02/13, indicated the resident was always continent of urine. A skilled nursing note written at 01:38 on 10/2/2013, stated: Resident alert and oriented . Communicates all needs effectively.Requires minimal assist from staff for adl's (activities of daily living). Transfers independently. Ambulates with walker with steady gait noted. Continent of bladder and bowel with occasional episodes of incontinence. No s/s of acute distress. Will continue to monitor. Call bell in reach. The quarterly MDS, with an assessment reference date (ARD) of 10/31/13 indicated he was frequently incontinent. A review of the progress notes from the assessment period for the quarterly MDS revealed on 10/23/13, 10/24/13, 10/26/13, 10/27/13, 10/28/13, and 10/31/13, the nursing staff had stated Resident #52 was continent of bowel and bladder. During an interview with Employee #116 (RN), at 11:15 a.m. on 01/14/14, he stated Resident #52 was not incontinent. The nurse reviewed the previous 30 days of task - aide documentation on the electronic record, and only two (2) incidents of incontinence were entered. The nurse stated the resident was even independent with his toileting. During an interview with Employees #55 and #99 (MDS nurses), at 12:00 noon on 01/14/14, they acknowledged, after reviewing the record, that the quarterly MDS was marked in error and should have been marked at 0 as the resident was not incontinent. They had no explanation for the error and stated the nurse who certified the completion and accuracy of the resident's functional status on the MDS was no longer an employee at the facility. Nurse #55 stated she would file a correction to the MDS in question. | 2018-05-01 |
| 6088 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 279 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan with individualized, measurable goals and interventions related to identified needs for eight (8) of thirty-four (34) sample residents and six (6) residents identified through random opportunities for identification during Stage 1 and Stage 2 of the Quality Indicator Survey (QIS) survey. Pacemakers were not addressed for Residents #5, #47, #68, #71, #84, #88, #104, #105, #115, and #134. Behaviors were not addressed for Residents #19, #62, #25, and #57. Resident identifiers: #5, #47, #68, #71, #84, #88, #104, #105, #115, #134, #19, #62, #25, and #57. Facility Census: 100. Findings include: a) Residents #5, #47, #68, #71, #84, #88, #104, #105, #115, and #134 On 01/13/14 at 2:00 p.m., a list was received from Employee #77, the Director of Nursing as requested, of the current residents who had cardiac pacemakers. These residents were on the list. The medical records of these residents were reviewed between 01/04/14 and 01/13/14. It was found all of these resident's care plans had cardiac pacemakers listed as a focus area. The interventions included (typed as written): pacemaker checks as ordered, dated and initiated by the nurse providing care. Further review of each care plan found the care plans did not identify the type of pacemaker, or whether the checks were to be performed within the facility or at a consulting Cardiologist's office. In addition, the care plans did not have individualized goals pertaining to the intervention of pacemaker check . for each resident. An interview was conducted with Employee #99, the Registered Nurse Assessment Coordinator (RNAC) on 01/24/14 at 8:00 a.m. After reviewing the care plans of these ten (10) residents, she commented the nurse who initiated interventions on a resident's care plan was responsible for also providing goals related to the intervention. Employee #99 also confirmed and agreed each of the resident's care plans should contain individualized measurable interventions and goals pertaining to each resident's cardiac pacemaker. b) Resident #19 Review of complaints, concerns, and abuse/neglect reporting began on 01/8/13 at 9:00 a.m. This review was continued and expanded on 01/20/14 as part of extended survey protocol. The review found Resident #19 had thirty (30) documented concerns in 2013 to date. Resident #19's physician had determined the resident possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score, as assessed on 12/17/13, was 15, indicating she was cognitively intact. She was acting as her own decision-maker. Review of her care plan, on 01/16/13 at 1:00 p.m., found she had a focus item for being at risk for changes in behavior problems related to making false accusations towards staff. The goal associated with this item was (typed as written): Will remain free of behavioral disturbances daily thru next review. Interventions implemented toward meeting this goal were (typed as written): 1. Anticipate needs and provide care as able. 2. Provide emotional support as needed. Review of the resident's comprehensive assessments found no indication this resident had behavioral problems. The resident's care plan did not indicate what constituted behavioral disturbances, which rendered it not measurable. The established interventions did not provide guidelines for direct care staff to enable them to provide consistent approaches to the behavior problems. There was no evidence found of what targeted behaviors were to be monitored, which would be needed to determine the effectiveness of the care plan interventions. In an interview with the acting nurse in charge, Employee #124, on 01/21/14 at 3:08 p.m., she was asked to provide any assessments or other documentation regarding behavior concerns for Residents #19. She provided selected nursing progress notes as follows: Progress notes were provided from 01/04/14, 01/09/14, 01/07/14, 01/06/14, 01/10/14, and 01/15/14 regarding the resident's refusal to wear hearing aids. A note, dated 01/12/14, identified the resident had complained to other residents Another resident had his pants down in the hallway and accusing staff of knowing about this and laughing at the situation. The note stated she did not ring call bell or did not come to nurses' station to inform any staff member of this situation. The note concluded the medical director in facility at desk and did not witness this. c) Resident #62 This resident had eleven (11) complaints/concerns/grievances documented. The resident's physician had determined the resident possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 01/09/14 was 15, indicating she was cognitively intact. She was acting as her own decision-maker. This individual was also the current president of the resident council. Review of her care plan, on 01/16/13 at 1:10 p.m., found she had a focus item for being at risk for behavior symptoms related to fabrications of staff refusing care/frequently making accusations toward staff and other residents. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Resident refuses psychiatric evaluation. 4. Use consistent approaches when giving care. The resident's comprehensive assessments did not identify this resident had any behavioral problems assessed. The goal was not stated in measurable terms. The only proactive intervention was to use consistent approaches when giving care. There were no guidelines provided to ensure consistent approaches were employed by direct care staff. In an interview with the acting nurse in charge, Employee #124, on 01/21/14 at 3:08 p.m., she was asked to provide any assessments or other documentation regarding behavior concerns Resident #62. She provided selected nursing progress notes as follows: Progress notes were provided from 12/03/13, 12/04/13 and 12/05/13 regarding her complaining of diarrhea, but refusing to provide a specimen. A note from 01/17/14 was provided in which she expressed concern about getting a roommate due to her preferences for cold temperatures and having a lot of personal belongings. d) Resident #25 There were nine (9) documented complaints/concerns/grievances for this resident. The resident's physician had determined this resident possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 10/18/13 was 15, indicating she was cognitively intact. She acted as her own decision-maker during her stay at the facility. Review of her care plan, on 01/16/13 at 1:37 p.m. found she had a focus item for being noted to make false accusations towards staff related to [MEDICAL CONDITIONS]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Use consistent approaches when giving care. The goal was not stated in measurable terms. The only proactive intervention was to use consistent approaches when giving care. There were no guidelines provided to ensure consistent approaches were employed by direct care staff. In an interview with the acting nurse in charge, Employee #124, on 01/21/14 at 3:08 p.m., she was asked to provide any assessments or other documentation regarding behavior concerns Resident #25. She provided selected nursing progress notes as follows: The nurse provided a progress note from 10/18/13 that stated (typed as written), Nurse was standing outside of room passing medications when resident call light came on. Nurse finished passing pills that were already started. Nurse answered call light. Resident states, 'It's about time my call light has been on for an hour.' Nurse explained to resident that she was standing outside of the room when the call light came on but I would be glad to assist her in repositioning. Resident states, 'You are just like everyone else, liars.' Will continue to monitor. She had a progress note dated 10/28/13 that stated: Received phone call at 0310 from residents daughter stating that the resident had called her and said that she couldn ' t reach her call bell and that she was falling out of bed. I told daughter I would go right back and check on resident. Upon entering the room resident found to be lying in the center of the bed and call light was on her left side. Resident states she is not happy about having to call to wake her daughter up. This nurse and CNA repositioned resident in bed and placed her call bell acrossed (sic) her chest at her request. e) Resident #57 Eight (8) complaints/concerns/grievances were documented for this resident. Resident #57 had a recent significant change of condition. Her physician had determined the resident lacked the capacity to make informed medical decisions on 12/27/13, due to illness/early dementia. Prior to that determination, she had acted as her own responsible party throughout her residency in 2013. Her Brief Interview for Mental Status (BIMS) score as assessed on 11/27/13 was 15, indicating she was cognitively intact. Review of her care plan, on 01/16/13 at 1:42 p.m. found she had a focus item for being at risk for behavior symptoms such as making false accusations towards staff and family related to mental illness and [MEDICAL CONDITION]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer meds per physician orders, observe for effectiveness and side effects such as but not limited to dizziness, drowsiness and falls. 2. If resident exhibits inappropriate behaviors, speak in a soft, calm tone, attempt to redirect, and encourage resident to express herself in a more appropriate manner. 3. Observe for mental status/behavior changes when new medication started or with changes in dosage. 4. Use consistent approaches when giving care. The goal was not stated in measurable terms. There were no guidelines provided to ensure consistent approaches were employed by direct care staff. In an interview with the acting nurse in charge, Employee #124, on 01/21/14 at 3:08 p.m., she was asked to provide any assessments or other documentation regarding behavior concerns Resident #57. She provided selected nursing progress notes as follows: The nurse provided notes regarding behaviors that occurred following the significant change of condition determination that resulted in the physician stating she no longer possessed the capacity to make informed medical decisions. f) Each of these residents had care plan focus items related to being at risk for behaviors due to making false allegations or fabrications. However, none of them had evidence of behaviors documented on their comprehensive minimum data set (MDS) assessments or any other systematic behavior monitoring that would have caused these focus items to be triggered for inclusion in their care plans. | 2018-05-01 |
| 6089 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 282 | D | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, procedure/policy review, and physician interview, the facility failed to provide or arrange services by qualified persons in accordance with the resident's written plan of care. The facility failed to identify Resident #5 had not had a cardiac pacemaker check in over a year. The facility also did not ensure evaluation of the effectiveness of Resident #130's pain medication as directed in his care plan. This was found for two (2) of thirty-four (34) Stage 2 sample residents. Resident identifiers: #5 and #130. Facility census: 100. Findings include: a) Resident #5 On 01/13/14 at 8:45 a.m., medical record review found the resident was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. A review of the care plan noted an intervention of pacemaker check as ordered. Review of the consultation report documentation revealed the resident had pacemaker checks dated 06/6/11, 03/12/12, and 12/11/12. In an interview, on 01/14/14 at 8:30 a.m., with Employee #116, who introduced himself as the Unit Manager (UM) for(NAME)Court, he confirmed Resident #5 had her most recent cardiac pacemaker check in December 2012. He stated the pacemaker check process was to place the physician appointment in the appointment book as recommended by the cardiologist. The consulting cardiologist reviewed his progress notes for Resident #5 and confirmed he had seen her in his office for a cardiac pacemaker check on 12/11/12. Resident #5 was given a return appointment card to be seen again in nine (9) months or sooner if there were any problems. He said her usual schedule was for her to be seen every nine (9) months. He stated she did not return for her scheduled appointment in September 2013. He further commented he was not aware the resident was on Hospice services, . but, either way a patient with a cardiac pacemaker still needs pacemaker checks. The facility had not ensured Resident #5 received checks of her pacemaker function in accordance with the established care plan. b) Resident #130 Review of the resident's medical record, on 01/14/14, noted the resident was admitted to Hospice services on 11/08/13 with a [DIAGNOSES REDACTED]. He had a care plan focus of At risk for pain. with a measurable goal stating Resident will verbalize pain is 0 per resident's pain goal per numeric scale. One (1) of the interventions with a focus on pain stated, Notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective. According to the medication administration record (MAR), the resident verbalized he had pain on 01/06/14. He rated his pain as a 4 on a 0 to 10 pain scale on 01/06/14. He was medicated with [MEDICATION NAME] 5/500 1 tablet at 8:30 a.m. by Employee #132, an agency Registered Nurse (RN). At no time on the MAR or in the Nursing Progress Notes was this resident's pain reassessed to determine effectiveness in accordance with the care plan. This information was shared with the Director of Nursing (DON), Employee #77, on 01/16/14 at 11:00 a.m. She said she recognized pain management was a problem in the facility. She provided audits she had completed, but they did not address pain reassessment after medication. She also provided a Pain Practice Guide issued 11/2011 by HCR Healthcare, LLC, which she indicated was the facility policy. On page nine (9) of this guide, it stated Patients are evaluated daily for evidence of pain. (sic) pain evaluation is also completed before and after PRN (as needed) medication administration. The patient's pain scale and score is recorded on the Medication Administration Record (MAR). | 2018-05-01 |
| 6090 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 371 | F | 0 | 1 | ZW4411 | Based observation and staff interview, the facility failed to ensure sanitary conditions were maintained in the kitchen. A ceiling vent over a sink was soiled with dust and debris. In addition, beverages stored in the refrigerators on the nursing units were not labeled to identify when they had been opened. This had the potential to affect all residents. Facility census: 100. Findings include: a) During the initial tour of the kitchen, at 2:30 p.m. on 01/06/14, observation of the ceiling vent over the pot-washing sink noted it was laden with dust webs and debris on the cross rails. Observations on a revisit at 11:45 a.m. on 01/09/14, noted it remained in the same condition. Employee #15 (Food Service Supervisor) was advised of this finding at 9:00 a.m. on 01/09/14. She said she would notify maintenance to clean it immediately. b) At 8:30 a.m. on 01/14/14, a tour of the nourishment kitchen on the 100/200 hall unit revealed an opened bulk container of orange juice and one of sweet tea in the refrigerator. Neither of these containers were labeled to identify when they had been opened. During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor), at 12:50 p.m. on 01/14/14, they were informed of the unlabeled drinks. | 2018-05-01 |
| 6091 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 431 | E | 0 | 1 | ZW4411 | Based on observation and staff interview, the facility failed to provide safe and secure storage of a medication cart. Observations noted an unlocked and unattended medication cart in the 300 hallway. This had the potential to affect more than a limited number of residents. Facility census: 100. Findings include: a) During observation of the 300 hall, at 11:40 a.m. on 01/07/14, the medication cart was unlocked and unattended at the nurses' station. There were no staff members in view of the cart. There were residents in the hall at that time. After a few minutes, Employee #36, Licensed Practical Nurse (LPN) approached the cart. She verified the cart was unlocked. She stated it was the medication cart she was responsible for that day on the 300 hall. In a discussion with the Administrator, on 01/16/14 at 10:00 a.m., she agreed the cart should not have been unlocked and unattended. | 2018-05-01 |
| 6092 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 441 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the spread of disease and infection. Two (2) employees were observed during meal service to have direct contact with a resident and the environment, then serve another resident without performing hand hygiene. The(NAME)Court nourishment kitchen floor was not maintained in a sanitary manner. These issues had the potential to affect all residents. Employee Identifiers: #7 and #66. Resident identifiers: #47 and #58. Findings include: a) Residents #47 and #58 On 01/07/14, observations were made of the lunch service on the 300-400 halls. At 11:50 a.m., Employee #7, Nurse Aide, served Resident #47's lunch tray. She applied a clothing protector to this resident, set up his tray, touched the over-bed table, and left the room. After exiting the room, she removed another tray from the food cart in the hall and served it without performing hand hygiene. At 12:15 p.m., Employee #66, housekeeper, served a tray to Resident #58. She applied a clothing protector to this resident, touched both the over-the-bed table and the bed linens. She then left the room, ran her fingers through her hair with both hands, and removed a tray from the food cart and served it to a resident in room [ROOM NUMBER] without performing hand sanitation. In interviews at that time, both employees stated the policy was to use hand sanitizer between trays and wash their hands every third tray. In an interview, on 01/16/14 at 9:00 a.m., Employee #61, housekeeper, stated housekeeping passes trays often, but not every day. This was confirmed with Employee #6, Environmental Services Supervisor 01/16/14 at 9:30 a.m. She said housekeepers received verbal training on how to set up trays. On 01/16/14 at 10:00 a.m., during an interview with the Administrator, she provided in-service information in which both Employees #7 and #66 had completed courses on hand washing and blood borne pathogens. According to the Annual Mandatory 2013: Infection Control and Prevention in-service from 2013 HCR Healthcare, LLC, It's important to practice hand hygiene upon leaving the patient's room. The Administrator said there should be no infection control concern with housekeepers passing trays, although she acknowledged in this case, there were concerns with the practices of both the nurse aide and the housekeeper. b) On 01/14/14 at 8:30 a.m., observations were made of the(NAME)Court nourishment room floor. There were multiple cracks in the tile. It was soiled. There were large pieces of tile missing from the floor. In a discussion of these findings, at the time of discovery, with Employee #87, Director of Maintenance, he stated he was aware of the tile problems, but had not gotten to it yet. | 2018-05-01 |
| 6093 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 463 | D | 0 | 1 | ZW4411 | Based on observation, resident interview, and staff interview, the facility failed to maintain a functioning call system for one (1) of thirty-five (35) Stage 2 sample residents and one (1) randomly observed resident during during Stage 1 of the Quality Indicator Survey (QIS) process. The call lights in the room of Residents #52 and #132 were not functioning. The call lights were adaptive call systems (rubber air bulb style), When the bulb call light was squeezed, it became flat and the call light did not come on to alert staff of the residents' need for assistance. Resident identifier: #132 and #52. Facility census: 100. Findings Include: a) Resident #132 On 01/07/14 at 2:30 p.m., during a room observation for Resident #132, it was discovered that her adaptive (rubber air bulb) call light was not operational and functioning when tested . The bulb became flat when squeezed and did not activate the call light to alert staff the resident needed assistance. The resident commented she was unaware it was not functioning. She said her husband, who was also her roommate, usually turned it on for her since she had vision problems and was legally blind. b) Resident #52 At 2:32 p.m. on 01/07/14, Resident #52's adaptive (rubber air bulb) call light was tested since he was in the same room as Resident #132. Resident #52's call light was not operational and functioning when tested . When the bulb was squeezed to call for assistance, it became flat and the call light did not come on to alert staff. Resident #52 commented the call light was working last night, but was unaware it was not working today. c) Employee #86, a Licensed Practical Nurse (LPN), verified these findings on 01/07/14 at 2:35 p.m. She agreed neither call light was functioning for either resident to call for assistance. d) Employee #116, a Direct Care Delivery/Registered Nurse (DCD/RN) replaced the call system with another adaptive rubber air bulb call light on 01/07/14 at 2:40 p.m. He commented the call system was working last night and the call lights were checked monthly by the Maintenance Department. e) In an interview Employee #87, the Maintenance Director, on 01/10/14 at 8:25 a.m. , he commented random checks were done monthly on five (5) to six (6) rooms on each wing and every three (3) months he checked all the call lights within the facility. He further commented the air bulb call lights would develop cracks in the rubber-like material. Employee #87 said this was the reason the call lights for Residents #132 and #52 malfunctioned during the inspection of the call lights. He explained the adaptive (rubber air bulb) call light had a bulb that deflated when squeezed to turn on the call light system for the residents. Employee #87 also commented the adaptive rubber air bulb call lights should be checked frequently since they developed cracks in the rubber. | 2018-05-01 |
| 6094 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 465 | E | 0 | 1 | ZW4411 | Based on observation and staff interview, the facility failed to maintain a safe, sanitary, and comfortable environment. During Stage 1 and Stage 2 of the Quality Indicator Survey (QIS), the hallways and five (5) of forty (40) rooms observed were in need of repairs. Torn pieces of wall coverings hung from the walls in the hallways. There were cracked and uneven tiles on the floor of the hallway leading to the main dining room. Tiles and caulking around toilets were stained and discolored. Plaster walls had cracks, stains, unpainted areas, gouges, and holes. Loose vinyl baseboard and scratched and scuffed doors were also noted. This practice had the potential to affect more than an isolated number of residents. Room numbers: #116, #117, #302, #309, and #400. Facility census: 100. Findings include: a) On 01/13/14, between 2:15 p.m. and 2:45 p.m., a tour of the facility was conducted, accompanied by Employee #87, the Director of Maintenance. The tour revealed the following issues: -- There were torn and hanging pieces of wallpaper-type covering observed on the hallway walls between rooms #403 and #404, #412 and #413, and #410 and #411. -- The entrance to the residents' main dining room had discolored, cracked, and uneven floor tile. -- Room #116 - There was stained and discolored caulking around the base of the toilet. -- Rooms #117 and #302 - The bathroom floors had stained and discolored tile surrounding the base of the toilet. -- Room #309 - The wall behind bed B had scraped areas and gouges in the wall with the unpainted plasterboard visible. There were also holes in the wall measuring 3 x 1, 1 x 1 and 1 x 1. Between the closet door and the bathroom door, the ceiling had cracked plaster, the wall had cracked and stained plaster, and the vinyl baseboard was loose from the wall. The interior portion of the bathroom door was scratched and contained torn jagged wooden type areas half (1/2) way up from the bottom of the door. -- Room #400 - The exterior door to the resident's room was scratched and scuffed. At the completion of the tour, Employee #87 stated he did monthly rounds to view and correct issues such as these. He agreed all of the identified problems needed corrected. He also agreed the entrance to the main dining room and the jagged and torn areas on the interior bathroom door were unsafe. Employee #87 further agreed the issues were not sanitary and did not provide a comfortable environment. | 2018-05-01 |
| 6095 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 490 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, review of facility policies, resident interviews, and staff interviews, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Multiple systems related failures were found with abuse/neglect prohibition, accuracy of information in medical records, maintenance of the physical environment, operationalization and implementation of facility specific policies and procedures, and the establishment of a functional, effective, quality assurance program. These systemic problems had the potential to result in harm to all residents in the facility. Facility census: 100 Findings include: a) Record review, staff interview, and policy review identified the facility failed to clarify and periodically review existing advance directives. Advanced directives were not accurately documented to effectively communicate the resident's choices to the direct care staff should the need to implement, or not implement, cardiopulmonary resuscitation (CPR) arise. This was true for four (4) of thirty-four (34) sample residents. Residents #114, #130, #99, and #5 ' s medical records had conflicting information about whether the individual to be a full code (resuscitated) or was not to be resuscitated. Licensed Practical Nurses, Employees #151, #69, #110, and #52 were asked what they looked at in the medical record to determine the code status. Based on the responses, it would be possible for nurses to look at the Condition Alert tab and find the resident was to be coded, while the physician's order [REDACTED]. The conflicting information found in the medical record and among staff members in regards to code status was discussed with the Administrator, Employee #120 and the Director of Care Delivery, Employee #124, Registered Nurse (RN) on [DATE] at 1:00 p.m. They acknowledged there was conflicting information in the residents' charts. A policy was provided titled Emergency Management code status identification revised ,[DATE]. This policy stated, Review and documentation of new physician orders [REDACTED]. Employee #120 stated a new process was going to be put into place effective immediately due to the breakdown of the current system. b) The facilityfailed to actively seek a resolution to grievances and/or to keep the resident informed of the progress being made. Residents had voiced reoccurring concerns regarding the availability and/or the variety of snacks available when the kitchen was closed; and/or the extended length of time required for care needs to be met for fifteen (15) of thirty (30) residents interviewed. Resident identifiers: #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, #141, #210 and #78. The resident interviews found snacks were not available to residents unless ordered by the physician. Observation of the unit nourishment kitchens found there were usually juice, crackers, tea, 4 individual cartons of milk (usually), and individual packets of peanut butter and jelly. The residents said once the main kitchen was closed, staff could not get them anything else. The residents had voiced this concern in resident council meetings, the Food Club, and to staff members. No resolution had been implemented, and residents had not been provided any information about resolution. The residents had also voiced complaints about staff responses to call lights. Residents #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, and #141 were interviewed and none could state what, if anything had been done to resolve the problem. This issue had been voiced in five (5) of the previous six (6) months resident council meetings. c) The facility failed to identify, report, and thoroughly investigate all allegations of abuse/neglect/mistreatment. Seven (7) of forty-three documented grievances/concerns were not reported to the appropriate State agencies. Additionally, the facility did not have evidence a thorough investigation had been conducted. The facility did not report and conduct a thorough investigation. 1) Resident #50 - the issues were items were not in reach, poor nail care, and poor response to call lights. There was no evidence the allegations of neglect were reported to the appropriate State agencies as required, nor was there evidence the allegations were thoroughly investigated. 2) Resident #148 - the resident complained antiembolitic stockings had been left on for two days and nights and when he asked to have them removed, the person said he/she would, but did not. No one was assigned to investigate this issue. It was not reported to the State agencies as neglect. 3) Resident #111 - the resident ' s sheets were wet with dried brown circles and even her hair was wet. The resident was cold and shivering. There was no documented evidence an investigation had been conducted other than Interviewed LN & CNAS (licensed nurse and certified nursing assistants) caring for resident during shift prior to reported concern. Care provided prior to end of shift and Investigation completed. Care determined to be provided. This was not reported to the State agencies as an allegation of neglect. 4) Resident #47 - complained she had not received therapy the continuous passive machine. This was not reported to the State agencies. 5) Resident #27 - complained Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. She did not want care from that aide again. This was not reported to the State agencies as neglect. The investigation consisted of a follow-up interview with Resident #17 and interviews with three (3) other residents. One of those residents (Resident #114) had the same complaint about the same aide. 6) Resident 71 - staff found a skin tear to the resident ' s right knee and a large bruise on his left lower back. The cause was unknown. The facility did not report this bruise of unknown origin to the appropriate State agencies and there was no investigation. 7) Resident #25 - the resident ' s daughter reported on a Monday ([DATE]) the resident had the same clothes on that she had worn on Saturday and she had no water. The cup in the resident ' s room was labeled from the ,[DATE] shift on Saturday night. The facility did not report these concerns as allegations of neglect. There was no evidence of any investigation. The Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation and the policies regarding grievances/complaints at 10:00 a.m. on [DATE]. She responded at 8:50 a.m. on [DATE] with the Patient Protection Practice Guide which stated in its opening paragraph, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. She was asked if there was a policy instructing staff of who and how to report to in this facility. At 10:50 a.m. on [DATE], she provided a one page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following and contained a list of agencies. She stated that she was the person ultimately responsible for reporting. The Administrator also provided a one-page instruction sheet, which accompanied the use of the concern form in use and a decision tree. She acknowledged that the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. d) Thirteen (13) of twenty (20) personal files reviewed did not have evidence of criminal background checks and/or evidence the abuse registry had been checked to make sure there were no findings of abuse/neglect/mistreatment for [REDACTED].#49, #15, #122, #119, #177, #178, #179, #180, #181, #182, #183, #184, and #187. f) The facility failed to maintain a safe, sanitary, and comfortable environment. During Stage 1 and Stage 2 of the Quality Indicator Survey (QIS), the hallways and five (5) of forty (40) rooms observed were in need for repairs. Torn pieces of wall coverings hung from the walls in the hallways. There were cracked and uneven tiles on the floor of the hallway leading to the main dining room. Tiles and caulking around toilets were stained and discolored. Plaster walls had cracks, stains, unpainted areas, gouges, and holes. Loose vinyl baseboard, scratched and scuffed doors were also noted. g) The facility failed to ensure the quality assurance program identified issues, implemented corrective actions, and monitored the corrective actions to ensure continued compliance. | 2018-05-01 |
| 6096 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 492 | F | 0 | 1 | ZW4411 | Based upon record review and staff interview conducted for each specific citation, the facility failed to operate and provide services in compliance with all applicable State and local laws, regulations, and codes. There were multiple deficient practices cited for failure to comply with West Virginia Nursing Home Licensure Rule 64CSR13. This had the potential to affect all residents. Facility census: 100. Findings include: a) The facility failed to develop and maintain written policies and procedures, and failed to ensure the policies and procedures were effectively operationalized by the facility as required by 64-13-10.3.d. The facility had not implemented policies and procedures regarding the investigation and reporting of allegations of abuse and neglect. b) The facility failed to maintain personnel files containing all required information as required by 64-13-11.6.a-i. Personnel files did not contain reference verifications, signed job descriptions, verification of current licenses, evidence of criminal background checks, evidence the abuse registry had been checked, and/or evaluations of work performance. c) The facility failed to have a written disaster and emergency preparedness plan that had been approved by the director as required by 64-13-9.11.b. | 2018-05-01 |
| 6097 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 493 | F | 0 | 1 | ZW4411 | Based upon record review, review of facility policy and procedure, and staff interviews the governing body, and designated administrator, failed to ensure policies regarding the management and operation of the facility were established and implemented. The facility failed to effectively maintain and operationalize policies and procedures. This had the potential to affect all residents. Facility census: 100. Findings include: a) The facility's failure to fully operationalize and maintain effective policies and procedures resulted in deficient practices being cited related to employee screening for abuse prevention. Review of thirteen (13) employees ' personnel files found the files did not contain all State required information, such as signed job descriptions, verification of current license/registration, evidence the nurse aide abuse registry and been checked to make sure the individual was not listed, etc. Three (3) of the thirteen (Employees #40, #119, and #49 did not have evidence of a statewide criminal background check. b) The facility failed to ensure allegations of abuse/neglect were identified, investigated, and reported to the appropriate administrative personnel and State agencies. The facility did not identify the staff member responsible for initiating the reporting process. Seven (7) of forty-three allegations of abuse/neglect were not thoroughly investigated and/or reported. (Resident identifiers: #50, #148, #111, #47, #27, #71, and #25.) c) Following the discovery of the lack of facility specific policies and procedures for abuse/neglect prohibition, a discussion was held with administrator, Employee # 120 on 01/20/14 at 9:00 a.m. She said the corporate owner of the facility had policies and procedures, which were available on the Internet, and these policies and procedures were revised and updated by corporate personnel as needed. There was no evidence that the facility itself had adopted them or that the medical director, administrator, director of nursing, or other department heads had read, reviewed them, and approved them as being appropriate, effective, and representative of what the facility actually does to protect and provide care for residents on a daily basis. d) When asked on 01/22/14 at 11:55 a.m. for documentation that the policies and procedures were maintained and operationalized by periodic review for continued effectiveness, administrator, Employee #120, furnished a Review and approval page from the Laundry Manual. The page consisted of the statement: The Laundry Manual is reviewed and approved to maintain current practices and healthcare industry standards by each of the following center representatives: Administrative Director of Nursing Services, Administrator, Medical Director, Housekeeping/Laundry Supervisor. The most recent dated signature section containing all four (4) signatures was dated 1/21/2010. When asked about other department policies and procedures, the administrator said the laundry review and approval was the most recent one she could find. She said that the corporation had done away with the process of facility management periodically reviewing and approving policies and procedures to ensure they were appropriate and customized for specific facility use because there was no tag for it. e) On 01/22/14 at 3:30 p.m., the Administrator was asked for evidence of a process to ensure that any revisions made to procedures at the corporate level were consistently communicated to the appropriate department manager, that facility management and the department manager evaluated and approved the revisions for adoption as specific facility procedure, and that any changes in daily work assignments and routines were promptly and effectively communicated to line staff responsible for changing the way they were actually carrying them out on a daily basis. On 01/23/14 at 11:00 a.m., evidence was furnished consisting of a regularly scheduled, annual infection control in-service. | 2018-05-01 |
| 6098 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 496 | E | 0 | 1 | ZW4411 | Based upon personnel file review and staff interview, the facility failed to ensure it had received registry verification that an individual met competency evaluation requirements before allowing an individual to serve as a nurse aide. This was found for two (2) of twenty (20) personnel records reviewed. This had the potential to affect more than a limited number of residents. Employee Identifiers: #37 and #93. Facility census: 100. Findings include: a) Ten (10) personnel files were reviewed on 01/13/14 at 10:00 a.m. The review found the facility failed to obtain registry verification for Employee #37 to ensure the individual met competency evaluation requirements before allowing the employee to serve as a nurse aide. b) During an interview with human resources director, Employee #40, on 01/13/13 at 11:00 a.m., she confirmed that the facility failed to obtain the required registry verification. c) An additional sample of ten (10) nursing assistants' personnel files was chosen at random to supplement the sample for an extended survey. These records were reviewed for registry verification on 01/20/14 at 1:00 p.m. The review found the facility failed to obtain registry verification that Employee #93 met the competency evaluation requirements before allowing the individual to serve as a nurse aide. | 2018-05-01 |
| 6099 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 503 | C | 0 | 1 | ZW4411 | Based on contract review and staff interview, the facility failed to maintain an agreement to obtain laboratory services from a laboratory that meets the applicable requirements. This practice has to potential to affect all residents. Facility census: 100. Findings include: a) On 01/23/14, during a review of contracts the facility had with outside agencies, a contract between a laboratory company and the facility was found. A former administrator had signed the contract, but it was not dated. The laboratory company portion had no signature. In an interview with the Administrator, on 01/23/14 at 10:00 a.m., she verified the facility still used that laboratory for services. She stated she did not have a signed and dated contract between the facility and the laboratory company. | 2018-05-01 |
| 6100 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 508 | D | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, staff interview, and physician interview, the facility failed to ensure the provision of diagnostic services to meet the needs of two (2) of eleven (11) residents with cardiac pacemakers. Resident #5 had a cardiac pacemaker for which the facility did not arrange cardiac pacemaker checks by the consulting cardiologist. Resident #74 was admitted with a pacemaker for which the facility did not determine if there was a need for a pacemaker check during his stay at the facility. Resident identifiers: #5 and #74. Facility Census: 100. Findings include: a) Resident #5 On 01/14/14 at 8:15 a.m., a medical record review was conducted for Resident #5. She was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the care plan found interventions of pacemaker check as ordered. Review of the consultation report documentation revealed the resident had pacemaker checks dated 06/06/11, 03/12/12, and 12/11/12. At 8:20 a.m. on 01/14/14, an interview was attempted with Resident #5. She was not able to be interviewed due to her cognitive status. An interview was conducted with Employee #116, who introduced himself as the Unit Manager (UM) for(NAME)Court on 01/14/14 at 8:30 a.m. During the interview, Employee #116 confirmed Resident #5 had her most recent cardiac pacemaker check in December 2012. He stated the pacemaker check process was to place the physician appointment in the appointment book as recommended by the Cardiologist. At 10:10 a.m. on 01/14/14, Employee#116 provided the requested cardiac pacemaker policy. He commented there was only a telephonic pacemaker policy. During the interview he stated according to the manufacturer's recommendation there was no specific time frame, it was determined by the physician. Employee #116 said usually the residents were seen by their cardiologist every three (3) to six (6) months, or for some it was nine (9) months to a year. He stated the pacemaker check for Resident #5 was overlooked by nursing and the physician. On 01/22/14 at 10:35 a.m., a telephone interview was conducted with the attending physician for Resident #5. The attending physician stated, I was not aware of her not having cardiac pacemaker checks until the 16th (01/16/14) of this month and gave the nurse a verbal order to discontinue pacemaker checks due to the resident's ailing health and being on Hospice. It should be noted, as of 01/14/14, the resident had not had a pacemaker check since 12/11/12. The order for its discontinuation was given after the identification of the facility's failure to ensure pacemaker checks was identified during the survey. A telephone interview was conducted with Resident #5's consulting Cardiologist at 2:30 p.m. on 01/22/14. The consulting Cardiologist stated cardiac pacemakers were checked sometime within a year depending on the type of pacemaker. The cardiologist said when the resident was seen in his office, a progress note or a return appointment card was sent back with the resident to the facility for the next pacemaker check appointment. The consulting Cardiologist reviewed his progress notes for Resident #5 and confirmed she was seen in his office for a cardiac pacemaker check on 12/11/12. Resident #5 was given a return appointment card to be seen again in nine (9) months or sooner if any problems - that was her usual schedule, to be seen every nine (9) months. He stated she did not return for her scheduled appointment in September 2013. He further commented he was not aware the resident was on Hospice services, but Either way a patient with a cardiac pacemaker still needs pacemaker checks. b) Resident #74 Review of this resident's medical record, on 01/14/14, revealed this resident was admitted on [DATE] and was discharged home on[DATE]. The resident's admission history and physical was completed by the Medical Director, Employee #102, on 07/18/13. Under past medical history, it was noted the resident had a pacemaker inserted. The 11/21/13 cumulative [DIAGNOSES REDACTED]. The nursing progress contained nothing which indicated an awareness the resident had a pacemaker. Both Physical therapy and Occupational therapy notes dated 10/03/13 and 10/14/13 (a total of four forms) listed pacemaker under the precautions area on the form. These forms were signed by the Medical Director, Employee #102. The care plan was reviewed. A pacemaker was not addressed for Resident #74. During the resident's stay, the need for pacemaker checks was never addressed by the physician. There was no evidence the facility evaluated if the resident's pacemaker was due for a routine check while he resided in the facility. This was discussed with the Administrator, Employee #120, on 01/14/14 at 2:00 p.m. She agreed it was problematic. | 2018-05-01 |
| 6101 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 510 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility obtained diagnostic tests without a physician's order for nine (9) of nine of thirty-four (34) sample residents whose medical records were reviewed during the Quality Indicator Survey. Nine (9) of nine (9) cardiac pacemaker checks were arranged and performed for residents without a physician's order to do so. Resident identifiers: #47, #68, #71, #84, #88, #104, #105, #115, and #134. Facility Census: 100. Findings include: a) Residents #47, #68, #71, #84, #88, #104, #105, #115, and #134 The care plans for these residents had cardiac pacemakers listed as a focus area. The interventions for each of the residents included (typed as written): Pacemaker checks as ordered. Each was dated and initiated by the nurse providing care. Further review of the medical records confirmed each resident had a cardiac pacemaker. None of the residents had a physician's order for pacemaker checks; however, each resident had a cardiac pacemaker check during 2012 or 2013. On 01/13/14 at 12:25 p.m., an interview was conducted with Employee #124, the Direct Care Delivery (DCD) Registered Nurse (RN) for Nutter Fort and Employee #77, the Director of Nursing (DON). Employee #124 stated, There are no written orders for pacemaker checks. She explained cardiac pacemaker checks were put in the appointment book when they were scheduled, and this was the facility's only means of tracking pacemaker checks for the residents. After a review of the care plans for the nine (9) residents, the RN, Employee #124, said If you want to argue verbiage, it is not correct. This statement was made regarding the care plan interventions which stated, pacemaker checks as ordered. The DON stated she would contact the corporate office regarding the residents not having a physician's order for cardiac pacemaker checks. She agreed it was a standard of practice to have a physician's order for diagnostic tests to be performed. At 1:50 p.m. on 01/13/14, an interview was conducted with the DON, after she contacted the corporate office consultants regarding the pacemaker checks. The DON stated, There is supposed to be a written physician order for [REDACTED]. She further commented, she was now aware the residents had been transported to the cardiologist offices for pacemaker checks without a written physician order. She also agreed the present system, for scheduled cardiac pacemakers checks only being recorded in the appointment book, needed to be re-evaluated to ensure a written physician order was obtained for the diagnostic test. | 2018-05-01 |
| 6102 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 514 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to maintain clinical records that were complete, accurately documented, readily accessible, and systematically organized for six (6) of thirty-four (34) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Code status was conflicting in the medical records for Residents #114, #130, #99, and #5. The medical record contained nursing progress notes in both paper and electronic formats for Residents #130 and #115. The nurse's notes in the medical record of Resident #74 did not note the resident had a pacemaker. There were blanks (no initials) in the medication administration records of Resident #114. Resident identifiers: #114, #130, #99, #5, #74, and #115. Facility census: 100. Findings include: a) Resident #114 Medical record review, on 01/16/14, revealed this resident had a FULL CODE sticker on the condition alert tab in his medical record. A green page in the medical record identified the resident was a Full Code status, as did the physician's orders [REDACTED]. The West Virginia Physician order [REDACTED]. It was marked Do Not Attempt Resuscitation. The POST form was signed by the medical power of attorney on 11/02/13 and by the physician on 12/12/13. b) Resident #130 Resident #130 was admitted to Hospice services on 11/08/13. The medical record contained a copy of a physician's prescription, dated 11/13/13, which stated, Please make patient DNR. A physician's orders [REDACTED]. The condition alert tab identified the resident was a FULL CODE. A green page in the medical record also stated Full Code. A sticker on this page stated Do Not Thin From Chart. In addition, nursing progress notes were found on the electronic medical records for all residents reviewed during the survey. On 01/16/14 handwritten paper nursing notes were found on the medical record. They were written by Employee #134, an Agency Registered Nurse (RN) on 09/06/13, Employee #131, an Agency Licensed Practical Nurse on 12/31/13, and Employee #132, an Agency RN, on 01/06/14. According to the Administrator, in an interview on 01/16/14 at 10:00 a.m., the start dates of these employees respectively were 09/13/13, 11/18/13, and 09/09/13. They still did not have computer access to the clinical record. The start date of Employee #134 was given as 09/13/13, This was after the date of her nursing note on 09/06/13. c) Resident #99 The condition alert tab in the medical record of Resident 99 did not contain the code status of Resident #99. A Medical Power of Attorney, notarized 10/04/13, included, Do Not Resuscitate. The physician's orders [REDACTED]. d) Resident #5 A POST form, signed by the physician on 09/07/13, indicated the resident's code status was Do Not Resuscitate. The physician's orders [REDACTED]. The condition alert tab, which was intended to be a reference, had a sticker stating FULL CODE. e) Staff interviews were held on 01/16/14 at 12:00 p.m. with licensed nurses on duty. Employee #151, an agency Licensed Practical Nurse (LPN), stated in an emergent situation regarding the resident's condition, she relied on the sticker on the Condition Alert tab as a reference. Employee #69, LPN, stated she also referred to the sticker on the Condition Alert tab. Another LPN, Employee #110, stated she looked for a red or green paper in the chart to let her know the code status of a resident and compared it to the POST form. Employee #52, LPN, stated she looked on the Condition Alert tab and compared it to the POST form. The conflicting information found in the medical record, and among staff members, in regards to code status, was discussed with the Administrator, Employee #120 and the Director of Care Delivery, Employee #124, Registered Nurse (RN), on 01/16/14 at 1:00 p.m. They acknowledged there was inaccurate information in the residents' medical records. A policy was provided titled Emergency Management Code Status Identification. This policy, revised November 2013, stated Review and documentation of new physician orders [REDACTED]. Employee 120 stated a new process was going to be put into place effective immediately due to the breakdown of the current system. f) Resident #74 A medical record review was performed on 01/14/14. An admission History and Physical (H&P) was completed for Resident #74 by the Medical Director, Employee #102 on 07/18/13. The H&P identified the resident had a pacemaker inserted under the section titled Past Surgical History. The [DIAGNOSES REDACTED]. The nursing progress notes did not describe the resident had a pacemaker. A review of the Minimum Data Sets (MDS) was completed for Resident #74 along with the Resident Assessment Coordinator, Employee #99. The MDS did not identify the resident's pacemaker. Both Physical therapy and Occupational therapy notes, dated 10/03/13 and 10/14/13, (a total of four (4) forms) listed pacemaker under the precautions area on the form. These forms were signed by the Medical Director, Employee #102. The care plan was reviewed. A pacemaker was not addressed for Resident #74. These lack of documentation regarding the resident's pacemaker was discussed with the Administrator, Employee #120, on 01/14/14 at 2:00 p.m. She agreed it was problematic. g) Resident #115 There were paper nursing notes on the medical record of Resident #115. The notes were written 08/03/13 by Employee #186 an Agency employee, a licensed nurse and on 01/16/14, by Employee #185, an Agency Licensed Practical Nurse. Their start dates were 09/26/13 and 09/10/13. On 01/16/14, the Administrator provided a policy titled Maintenance of Hybrid Health Record. The policy, dated 08/26/09, did not address combining all nursing notes in one form, whether it be paper or electronic; however, it listed several staff members who had permission to approve access to the electronic record for employees to perform their job duties. The Administrator did not provide an explanation regarding why the employees who were hired in 2013 would not have access to all of the medical record if needed. She said there was a problem getting access for Agency Nurses. The administrator said there were times when both nurses working at a nurse's station would be Agency employees. She said it was possible neither nurse would have access to the medical record during their shift, unless they contacted an employee on the other side of the building. The medical record was not systematically organized or readily accessible to all nurses. h) Resident #114 This resident's Medication Administration Record [REDACTED]. The nurse had not signed off as given for the 6:00 a.m. doses of medications on 01/09/14. The medications due at that time were [MEDICATION NAME] 5 milligrams (mg) orally and Tamsulosin 0.4 mg orally. Additionally, pain assessments were not initialed as completed on 01/09/14 and 01/13/14. Employee #124, Director of Care Delivery, was interviewed at 2:00 p.m. on 01/14/14 She said the resident was not out of the building at 6:00 a.m. It was unclear if the resident received his medication, as the medical record was not complete. | 2018-05-01 |
| 6103 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 520 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, staff interviews, record review, facility policy and procedure review, and review of other facility documents, the quality assessment and assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge. The QAA Committed failed to implement plans of action to correct identified problems, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The QAA committee identified area as permanent items on their monthly agenda. Items included on the monthly agenda, which were identified as deficient practices during the survey included abuse/neglect reporting and investigation, complaints, and environmental issues. These quality deficiencies were not effectively addressed, as allegations of neglect and complaints related to resident life in the facility continued to not be identified, investigated, and/or reported as appropriate. In addition, there was no follow-up to prevent recurrence. Environment was also an identified deficit during the survey. There was no evidence the QAA committee effectively addressed this area of concern which had previously been identified by the facility. In addition, the facility failed to recognize the need to obtain physician orders [REDACTED]. These practices had the potential to affect all residents residing in the facility. Findings include: I) The facility failed to develop facility specific policies and procedures regarding identification, investigation and reporting of allegations of resident mistreatment, neglect, abuse and misappropriation of resident property. The facility had no facility specific written policies and procedures which included procedures for investigating different types of incidents, identifying the staff member responsible for the initial reporting, reporting of results to the proper authorities, and identifying what constituted an allegation of abuse, neglect, or mistreatment of [REDACTED]. This was found for thirteen (13) of twenty-one (21) employees reviewed (Employees #119, #49, #15, #122, #177, #178, #179, #180, #181, #182, #183, #184, and #187). The residents affected included Residents #50, #148, #111, #47, #27, #71, and #25; however, the practice had the potential to affect all residents. During the survey, seven (7), of forty-three (43) Concern Reports reviewed, which should have been reported to the appropriate State agencies as allegations of neglect or mistreatment of [REDACTED]. In addition, the facility failed to thoroughly investigate the allegations. Affected residents were Residents #50, #148, #111, #47, #27, #71, and #25. Below are the allegations which were not addressed as required: 1) Resident #50 During a care plan meeting on 01/09/14, attended by the resident and a family member, the following allegations of neglect were made: -- The resident's trash can and/or phone were frequently not within reach of the resident. -- The resident was receiving poor nail care. -- The resident stated he gets poor response time to his call light. 2) Resident #148 Resident #148 voiced a complaint of neglect to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose were on at that time. The resident told the therapist they had been left on for two (2) days and nights, when they were supposed to be taken off at night. He also stated he had asked someone to take them off and they said they would, but did not. 3) Resident #111 A concern form regarding neglect was, Resident (#111) found in bed (sign for 'with') wet sheet, dried brown urine circled on sheets. Resident's hair even saturated (sign for 'with') urine. Resident was cold, wet and shivering. 4) Resident #47 A concern form regarding neglect for this resident noted, Resident voiced that she has not been receiving CPM (continuous passive motion) machine (ordered therapy). The resident reported this to Employee #79 (Occupational Therapist) on 12/22/13, who filed the concern form. 5) Resident #27 On 12/23/13, the resident reported neglect to Employee #88 (LPN Supervisor). The resident said Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. The resident said she did not want care from that aide again. 6) Resident #71 An injury of unknown origin was reported to staff regarding a skin tear to the right knee and a large bruise on the left lower back of Resident #71 when he was bathed at 12:30 p.m. on 12/03/13. The resident denied any falls and staff documented, Unsure as to exact cause. 7) Resident #25 The family of Resident #25 reported a concern of neglect to Employee #88 (LPN Supervisor) on Monday, 10/14/13. The family visited on Sunday evening (10/13/13) and Resident #25 was wearing the same clothes she was dressed in on Saturday morning (10/12/13). The concern also alleged the resident had no water on Sunday evening. The cup in the resident's room was labeled as provided on the 11-7 shift on Saturday night. 8) Various employees handled the concerns. Employee #116 (RN) had handled several of the concerns. During an interview at 1:00 p.m. on 01/14/14, he stated he assumed the decision had regarding reporting had already been made when he was given the concern to resolve. When asked who was responsible for reporting allegations to the State, his response was Social Services. During an interview with Employee #57 (LPN - Supervisor), at 11:50 p.m. on 01/14/14, she was asked to whom she reported concerns/allegations from the residents. She said she reported them to the director of nurses or the oncoming supervisor. She did not know who reported them to the State. In an interview with Employee #122 (Social Worker), at 09:45 a.m. on 01/14/14, she was asked who was responsible for reporting allegations of abuse/neglect to the State. Her answer was Employee #175 (Social Worker) who was the Patient Advocate. Due to the confusion displayed by front-line employees, at 10:00 a.m. on 01/14/14, the Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation of resident property. She was also asked to provide the policies regarding grievances/complaints. The administrator responded at 8:50 a.m. on 01/15/14, with a commercially printed excerpt entitled: Patient Protection Practice Guide. Its opening paragraph stated, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. The guide contained no procedures individualized to the facility. When asked if there was a facility policy which specifically instructed staff to whom and how to report allegations, the administrator stated, I don't think so. At that time, the administrator said she was the person ultimately responsible for reporting. At 10:50 a.m. on 01/15/14, the administrator provided a one (1) page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following. The paper contained a list of agencies. The Administrator also provided a one-page instruction sheet which accompanied a decision tree relative to the use of the concern form. She acknowledged the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. On 01/15/14 at 10:50 a.m., the Administrator stated there was no evidence to show the facility's review and/or acceptance of these documents. She also stated she was unable to locate facility specific policies. The Administrator said she had called an ad hoc Quality Assurance meeting to address the discovery that the facility had no abuse/neglect policy. An interview was conducted with the Administrator, the Social Worker (Employee #175) and the Director of Nursing (Employee #77) At 11:20 a.m. on 01/15/14. All members of the survey team were present. The concerns which should have been reported and investigated, but were not were discussed. The facility was unable to provide additional evidence for these allegations of neglect. The administrator acknowledged the lack of individualized facility policies might have resulted in the allegations not being reported. b) Employees #119 and #49 Ten (10) personnel files were reviewed on 1/13/14 at 10:00 a.m. The review found the facility failed to obtain statewide criminal background checks for two (2) of the ten (10) records reviewed. This was found for Employee #119 (Housekeeping) and Employee #49 (Nurse Aide). c) Employees #15 and #122 The facility also failed to verify that two (2) prospective employees and eight (8) contracted staff did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was found for Employee #15 (Nurse Aide) and Employee #122 (Social Worker). During an interview with human resources director, Employee #40 on 01/13/13 at 11:00 a.m., she confirmed the facility failed to screen all potential employees for statewide criminal background or a history of abuse, neglect or mistreating residents as required. d) Contracted Employees #177, #178, #179, #180, #181, #182, #183, #184, and #187 (a Registered nurse, 2 Cooks, and 6 Dietary Aides) On 1/21/14 at 1:30 p.m., it was discovered that contracted dietary employees were not included on the employee list. A list of contracted dietary employees was requested. Review of the eight (8) files for these staff found none of them had verification that they did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was confirmed by administrator, Employee #120 on 01/21/14 at 2:00 p.m. On the morning of 01/23/14, it was found there were once again additional agency staff working in the building. Information was requested on these three (3) nurses. On 01/23/14 at 1:58 p.m., human resources director, Employee #40 confirmed that for a registered nurse, Employee #187, the facility had no documentation of current license, state wide criminal background check, or verification that she did not have findings of abuse, neglect, or misappropriation of funds prior to allowing her to have contact with residents. II) The facility failed to ensure all allegations of mistreatment, neglect, injury of unknown origin, or abuse were reported immediately to the appropriate State agencies in accordance with this regulation and with Code of State Rules, Title 64 Series 13 - Nursing Home Licensure Rule for West Virginia. The facility also failed to have evidence all allegations were thoroughly investigated. This was found for seven (7) of forty-three (43) documented grievances/concerns reviewed. Additionally, the facility had not ensured it did not employee individuals who had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. Thirteen (13) of twenty (20) personal files reviewed did not have this information. Employee identifiers: #49, #15, #122, #119, #177, #178, #179, #180, #181, #182, #183, #184, and #187. Resident identifiers: #50, #148, #111, #47, #27, #71, and #25. 1) Resident #50 A review of a Concern Form revealed the son of Resident #50 made the following allegations during the course of a care plan meeting attended by both the resident and his son on 01/09/14: 1. Resident #50's trash can and/or phone were frequently not within the reach of the resident. 2. The resident was receiving poor nail care. 3. Resident #50 stated he gets poor response time to his call light. A written report was completed for each of these allegations on 01/09/14. The concerns were assigned to Employee #116 (RN and Director of Care Delivery) on 01/10/14, to be resolved by 01/15/14. Notices were distributed to All nursing staff in service on 01/10/14, instructing corrective action to be taken regarding the allegations and the following Resolution of Concern was written on the forms and signed by Nurse #116 - At this time, resident et (and) family are satisfied (sign for 'with') actions taken by facility to correct these concerns. Will cont. (continue) ongoing communication (sign for 'with') resident et family to ensure concerns are resolved. There was no evidence the allegations of neglect were reported to the appropriate State agencies as required, nor was there evidence the allegations were thoroughly investigated. 2) Resident #148 Review of a facility Concern Form revealed Resident #148 had voiced a complaint to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose were on at that time. The resident told the therapist they had been left on for two (2) days and nights, when they were supposed to be taken off at night. He also stated he had asked someone to take them off and they said they would, but did not. An incident report was also filed and the resident's physician was informed. The form was signed by Employee #77 (Director of Nursing), but no one was assigned to take action on this concern. There was a partially completed State Report attached to the Concern form, but there was no evidence the resident's allegation of neglect was either reported to the appropriate State agencies, or that any type of investigation had been made. There was no indication the facility staff had notified the resident of any action taken to ensure this did not reoccur. 3) Resident #111 A concern form, reviewed, at 10:00 a.m. on 01/14/14, included Resident (#111) found in bed (sign for 'with') wet sheet, dried brown urine circled on sheets. Resident's hair even saturated (sign for 'with') urine. Resident was cold, wet and shivering. The date on the form was 12/20/13 at 8:30 a.m., but it did not state who found the resident in that condition. A nurse (no longer at the facility) was assigned the concern for resolution on 12/21/13. There was no other indication of her involvement. A nurse, Employee #124, completed an incident report on 12/20/13, which noted the family was notified. Employee #77 (Director of Nursing) documented Interviewed LN & CNAS (licensed nurse and certified nursing assistants) caring for resident during shift prior to reported concern. Care provided prior to end of shift and Investigation completed. Care determined to be provided. The completion date on the form was 12/22/13. There was no attached evidence of an investigation. There was no evidence this occurrence was recognized as an allegation of neglect and reported to the appropriate State agencies. When questioned about the incident, at 11:15 a.m. on 01/14/14, Employee #77 confirmed there was no additional information filed, although she did say she talked to the nurse who was working at the time of the incident. 4) Resident #47 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, found a concern form for this resident noted, Resident voiced that she has not been receiving CPM (continuous passive motion) machine (ordered therapy). The resident reported this to Employee #79 (Occupational Therapist) on 12/22/13, who filed the concern form. This allegation of neglect was not reported to the appropriate State agencies and a thorough investigation was not completed. Employee #116 (nurse) was assigned to take action on the concern. The record indicated his determination that the therapy had not been completed on 12/19/14, and Employee #88 (LPN) had confirmed this in a signed statement. Employee #116 indicated he had discovered four (4) missed treatments between 12/19/13 and 12/22/13 and stated in the report that the resident had confirmed the missed treatments. There were no other interviews or information collected. The resolution was education for the staff nurse identified for the single omission on 12/19/14. During an interview with Employee #116 at 1:00 p.m. on 01/14/14, he stated it was given to him as a concern only and he assumed the decision about reporting had already been made. 5) Resident #27 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, revealed a concern reported to Employee #88 (LPN Supervisor) on 12/23/13, by Resident #27. Resident #27 stated Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. She did not want care from that aide again. The facility did not recognize this as allegations of neglect and did not report the allegations to the appropriate State agencies. The investigation contained only a follow-up interview with Resident #27 and interviews with three (3) other residents. One (Resident #141) had the same complaint about the same aide. 6) Resident #71 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed staff reported a skin tear to the right knee and a large bruise on the left lower back of Resident #71 when he was bathed at 12:30 p.m. on 12/03/13. The resident denied any falls and staff documented, Unsure as to exact cause. The facility did not report this bruise of unknown origin to the appropriate State agencies and there was no investigation. There was an entry which stated, Res (resident) did sit down hard in w/c (wheelchair) one day last week when he almost missed the chair. At the time of discovery, no description of the bruise was documented to assist in determining the age of the bruise and no evidence that staff interviews had been done. 7) Resident #25 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed the daughter of Resident #25 had reported a concern to Employee #88 (LPN Supervisor) on Monday, 10/14/13. The daughter visited on Sunday evening (10/13/13) and Resident #25 was wearing the same clothes she was dressed in on Saturday morning (10/12/13) and had no water. The cup in her room was labeled from the 11-7 shift on Saturday night. The facility did not report these concerns as allegations of neglect. There was no evidence of any investigation. 8) The Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation and the policies regarding grievances/complaints at 10:00 a.m. on 01/14/14. She responded at 8:50 a.m. on 01/15/14 with the Patient Protection Practice Guide which stated in its opening paragraph, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. She was asked if there was a policy instructing staff of who and how to report to in this facility. At 10:50 a.m. on 01/15/14, she provided a one page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following and contained a list of agencies. She stated that she was the person ultimately responsible for reporting. The Administrator also provided a one-page instruction sheet, which accompanied the use of the concern form in use and a decision tree. She acknowledged that the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. The Administrator stated there was no evidence to show that the facility's review and/or acceptance of these documents and she could locate no facility distinct policies. An interview with the Administrator, Employee #175 (Social Worker), and Employee #77 (Director of Nursing), along with the survey team, was conducted at 11:20 a.m. on 01/15/14, to review the above Concern Forms. The facility provided no additional evidence regarding these occurrences as of the time of exit. The administrator acknowledged that the lack of individualized policies to follow might have resulted in the allegations not being reported. 9) Review of personnel files found the facility had not ensured thorough background checks and/or abuse registry checks had been conducted for all employees. These findings were verified on 01/13/14 at 11:00 a.m. by Employee #40, the human resource manager. The following issues were found: a) Employee #49 The facility had no evidence of statewide criminal background check had been completed for this nurse aide. b) Employee #15 The facility did not have evidence the abuse registry had been checked for this dietary employee. c) Employee #122 There was no evidence the abuse registry had been checked for this social worker. d) Employee #119 No evidence of a statewide criminal background check was found in this housekeeper's file. e) Employee #187 There was no evidence this nurse had had a statewide criminal background check. f) On 01/21/14 at 1:30 p.m., it was discovered that contracted dietary employees were not included on the employee list. A list of contracted dietary employees was requested. Review of the eight (8) files for these staff found none of them had verification that they did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was confirmed by administrator, Employee #120 on 01/21/14 at 2:00 p.m. These contracted employees were #177, #178, #179, #180, #181, #182, #183, #184, and #187 (a Registered nurse, 2 Cooks, and 6 Dietary Aides) III) The facility failed to actively seek a resolution to grievances and/or to keep the resident informed of the progress being made. Residents had voiced reoccurring concerns regarding the availability and/or the variety of snacks available when the kitchen was closed; and/or the extended length of time required for care needs to be met for fifteen (15) of thirty (30) residents interviewed. Resident identifiers: #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, #141, #210 and #78. 1) Resident #62 During an interview with Resident #62 at 3:30 p.m. on 01/07/14, during Stage 1 of the survey, she said there were few or no snacks kept on the care unit and if you requested something when the kitchen was not open you could not get it. She stated this was true for both food and/or drinks. The resident said she had stated this concern during resident council meetings, to the dietitian, at food club meetings, and to the nursing care staff, but nothing had been done. The only answer she received was from a nursing assistant, who said the kitchen would not stock snacks on the unit. 2) Resident #78 An interview with Resident #78 at 2:00 p.m. on 01/08/14, revealed she agreed there were few, if any, snacks available. She stated, If you want a snack they have to go to the kitchen to get it and you can't get anything when the kitchen is closed in the evening. She added, If you wanted something you should have the physician order [REDACTED]. According to the resident, there was usually juice or tea and crackers kept on the unit, but nothing more. She added that this had been brought up at resident council and she had voiced it to nursing staff and the kitchen staff, but she was told there was nothing they could do. 3) As a result of these interviews, the following observations were made during the survey: Observations of the nourishment kitchen serving the 300/400 halls were made at 8:30 a.m. on 01/08/14; 9:30 a.m. on 01/09/14; 3:00 p.m. on 01/13/14; and 8:15 a.m. on 01/14/14 (on 01/14/14 Employee #87 (Maintenance Director) was present). On each of these observations, there were only graham crackers, soda crackers, and individual containers of peanut butter and jelly found. The refrigerator contained orange juice and a large container of tea. There were never more than four (4) individual containers of milk. There was ice cream in the freezer, but no fruit, puddings, cookies, or bread. 4) Observations of the nourishment kitchen serving the 100/200 halls were made at 8:45 a.m. on 1/08/14; 2:00 p.m. on 01/09/14; and 8:15 a.m. on 01/14/14. The only snack items available were graham crackers, soda crackers, and individual containers of jelly and peanut butter. On 01/14/14, there was a partial loaf of bread. The refrigerator contained large containers of sweetened iced tea and orange juice and ice cream. There were no puddings, cookies, or fruits. There was no milk on 01/08/14 or 01/09/14 and only four (4) individual containers of milk on 01/14/14. 5) All observations revealed multiple individual containers of ordered supplements labeled for certain residents. There were also cans of soda, provided by purchasing. 6) At 9:30 a.m. on 01/14/14, following the earlier observation at 8:15 a.m., both nourishment kitchens were stocked with at least a dozen individual containers of milk, 3 cans of soup, bread, 4 puddings, and a 2 covered bowls of canned fruit. Employee #18 (Aide), who was present, stated this was . a lot more than we usually have. They continued to be stocked throughout the remainder of the survey. 7) An additional six (6) resident interviews were completed during Stage 2 of the survey at 8:30 a.m. on 01/16/14. The residents were asked, Can you get a snack in the evening? and What would you like to get?. The responses were: 1) Resident #64: . no snacks unless the kitchen sends them. When asked what she would like to have she said Maybe a sandwich or toast. 2) Resident #15: You get drinks for snacks if you ask for one. He said he would like food. 3) Resident #133: No snacks. The resident said he would like A sandwich. 4) Resident #115: They don't bring snacks. They tell you, 'no extra.' She said she prefers fruit or cookies and milk. 5) Resident #58: They don't keep anything but crackers. She said she would like anything but crackers. 6) Resident #210: You only get a snack if you're a diabetic. The resident said cookies would be nice. All of these residents stated they had questioned the staff about snacks, but it had not resulted in them being provided. Some said they just get their family to bring things in. None of the residents had been told why their requests had not been met. 8) During an interview with Employee #109 (Activity Director), at 10:30 a.m. on 01/08/14, she was asked to explain some of the items on the Resident Council Minutes form as she attended the meetings. One of the items listed under, Compliments, comments, on 08/15/13, was Snack machine items - Would like switched but they state they cannot change them. She explained that the residents used the snack machine a lot and when asked, added that the residents say there are not a lot of snacks on the floor in the evening. She stated she had forwarded these complaints to the dietary supervisor and administration. She was not aware of any action taken. In an interview with the Registered Dietitians, at 11:35 a.m. on 01/08/14, they acknowledged awareness of the lack of snacks stocked in the nourishment kitchens and stated they had no control over this as the food supplies were provided by contract with a contracted company. The dietitian who did the assessments said, when interviewing residents, she asked them if they wanted a snack and what their preferences were. She then added it to their food order and had the kitchen send them out, but she stated she only did this for the residents who wanted a snack on a daily basis. The Senior Dietitian stated the nourishment kitchens were stocked daily in the afternoon by the kitchen from a written request from the unit nurse and signed for by a nurse when received. She also stated the aides sign out snacks when they are taken from the room and provided a copy of the Nourishment Room Snack Sign Out Log for January 2013. 9) During an observation of the nourishment kitchens at 1:00 p.m. on 01/08/14, the sign out logs were absent. Employees #98, #7, and #142 (aides) stated they were not required to sign out items from the nourishment kitchen. Employees #116 and #106 (Nurses) verified there was no sign out form in use. Employee #116 stated there had been such a form but the practice had only been in effect for about a month and was dropped. 10) The Senior Dietitian provided an order for [REDACTED]. Of the four (4) types of milk, only a few containers of 2% milk were observed. 11) During an interview with Employee #15 (Food Service Supervisor), at 9:00 a.m. on 01/09/14, she acknowledged the use of the sign-out form for snacks but agreed it had not been used. for a long time. She stated the kitchen did not provide soft drinks, except for ginger ale for therapeutic use. She admitted awareness of complaints from time to time from the residents about snacks, but stated there was nothing she could do about it and did not explain. She provided a copy of the HCR ManorCare HS Snack Rotation schedule which listed puddings, cookies, ice cream, peanut butter crackers, pretzels,cheese its, and graham crackers. 12) An evening visit at 11:30 p.m. on 01/14/14, revealed the same snack items (and same amount) present in the nourishment kitchens as on the earlier visit on the same day (9:30 a.m.). Interviews with Employees #28, #37, #164, #32, and #20 (aides) revealed they had delivered the labeled HS (bedtime) snacks, but had not offered any additional snacks and none had been requested by residents. They expressed surprise at the amount of snacks available and stated that there was usually only Jugs of tea and a juice, and crackers. Employees #32 and #20 stated Resident #29, who was yelling out at that time, could be calmed at times by getting her up and giving her a sandwich, but there was never anything to fix a sandwich with. All of them agreed with this and all agreed a sandwich or toast was the most requested snack. The aides reviewed the HS (hour of sleep) Snack list and said it appeared accurate, but all stated, except for graham crackers and ice cream, none of these items were stocked in the nourishment kitchens. 13) During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor) at 12:50 p.m. on 01/14/14, Employee #15 was asked if she had met with the residents to listen to their concerns/requests regarding snacks. She stated a Food Committee met periodically to discuss issues with the food and she attended these meetings, but she had no authority to promise them snacks. She stated she had forwarded the residents' requests to Administration in the past. 14) In a (TRUNCATED) | 2018-05-01 |
| 6254 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 272 | D | 0 | 1 | 4OKO11 | Based on medical record review and staff interview, the facility failed to accurately assess one (1) of twenty-three (23) Stage 2 residents. A comprehensive assessment was coded inaccurately for pressure ulcers. Resident identifier: Resident #66. Facility census: 88. Findings include: a) Resident #66 This resident's medical record was reviewed on 01/22/14 at 12:16 p.m., and revealed the resident's history of pressure ulcers since admission. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/18/13, was coded 1 under Item M0210, which indicates the presence of one or more unhealed pressure ulcers at Stage 1 or higher. Item M0900, was coded 1, which indicated pressure ulcers were present on the prior assessment. The annual MDS assessment, with an ARD of 12/18/13, was coded 0, under Item M0900, which indicated pressure ulcers were not present on the prior assessment. An interview conducted with Employee #102 (Registered Nurse Assessment Coordinator), on 01/22/14 at 4:20 p.m., confirmed the MDS assessment was coded incorrectly. | 2018-04-01 |
| 6255 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 278 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the health professional who completed Item M0900, healed pressure ulcers, of the comprehensive assessment for one (1) of twenty-three (23) Stage 2 sample residents certified the accuracy of this portion; however, Item M0900 did not accurately reflect the resident's pressure ulcer status. Resident identifier: #66. Facility Census: 88. Findings include: a) Resident #66 Review of the medical record on 01/22/14 at 12:16 p.m., revealed Resident #66 had a history of [REDACTED]. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/18/13, was coded as 1 for Item M0210, which indicated the presence of one or more unhealed pressure ulcers at Stage 1 or higher. The annual MDS assessment, with an ARD of 12/18/13, was coded 0, for Item M0900, which indicated pressure ulcers were not present on the prior assessment. An interview conducted with Employee #102 (Registered Nurse Assessment Coordinator), on 01/22/14 at 4:20 p.m. confirmed the MDS assessment had been coded inaccurately. | 2018-04-01 |
| 6256 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 279 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans which described the care and services necessary to meet the medical, mental, and/or psychosocial needs for four (4) of twenty-three (23) residents in Stage 2 of the Quality Indicator Survey. The care plans lacked nonpharmacologic interventions for conditions being treated with [MEDICAL CONDITION] medications, in an effort to reduce or eliminate the use of the medications. Resident identifiers: #91, #104, #151, and #87. Facility census: 88. Findings include: a) Resident #91 Medical record review revealed Resident #91 was prescribed [MEDICATION NAME] for a [MEDICAL CONDITION],[MEDICATION NAME], and [MEDICATION NAME] for anxiety. Review of the medical records revealed the care plan did not identify specific nonpharmacologic interventions to address the resident's [MEDICAL CONDITIONS], and anxiety. On 01/23/14 at 10:43 a.m., registered nurse, Employee #102, acknowledged there were no nonpharmacologic interventions in the care plan for this resident. b) Resident #104 Medical record review revealed Resident #104 was currently [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] for anxiety, and [MEDICATION NAME], and [MEDICATION NAME] for a [MEDICAL CONDITION]. Review of the medical records revealed the care plan did not include nonpharmacologic interventions for the resident's [MEDICAL CONDITION], anxiety, or [MEDICAL CONDITION] in an effort to reduce or eliminate the use of the pharmaceuticals. On 01/23/14 at 10:43 a.m., register nurse, Employee #102, acknowledged there were no nonpharmacologic interventions in the resident's care plan to address the conditions for which the resident was receiving medications. c) Resident #151 Medical record review revealed Resident #151 was prescribed [MEDICATION NAME] related to a [MEDICAL CONDITION] to [MEDICAL CONDITION]. Review of the medical records revealed the resident's care plan did not identify specific nonpharmacologic interventions to address the resident's [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 01/23/14 at 10:43 a.m., registered nurse, Employee #102 acknowledged there were no nonpharmacologic interventions identified in the resident's care plan. d) Resident #87 On 01/23/14 at 4:12 p.m., a review of Resident #87's care plan revealed an intervention Attempt interventions before my behaviors begin. No evidence could be found as to what interventions were to be attempted. In an interview on 01/23/14 at 3:43 p.m., the director of nursing stated there was no reason to discuss this as the care plan for this resident was not complete with interventions to attempt before behaviors began. | 2018-04-01 |
| 6257 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 280 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to update a care plan to reflect the resident's current medical condition. This was found for one (1) of twenty-three (23) Stage 2 sample residents. Resident #99's current care plan contained goals and interventions for insulin dependent diabetes, a [DIAGNOSES REDACTED]. Resident identifier: #99. Facility census: 88. Findings include: a) Resident #99 Review of the resident's medical record, on 01/22/14 at 8:30 a.m., revealed Resident #99's current medical [DIAGNOSES REDACTED]. The resident's current care plan, dated 12/16/13, and updated on 12/31/13, listed insulin dependent diabetes as a current diagnosis. Goals and interventions had been established and remained a part of the care plan. Further review of the Medication Administration Record [REDACTED]. An interview was conducted with Employee #102 (registered nurse assessment coordinator) on 01/22/14 at 11:18 a.m. She reviewed the resident's current Medication Administration Record [REDACTED]. She acknowledged the resident was no longer receiving insulin and agreed the care plan needed to be revised to indicate this issue was resolved. | 2018-04-01 |
| 6258 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 282 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and observation the facility failed to provide care as indicated on the care plan for six (6) of twenty-three (23) Stage 2 quality indicator survey, sample residents. Residents #91, #104, #151, #147, and #87's care plans included monitoring for side effects of [MEDICAL CONDITION] medications. This monitoring did not occur. Resident #71's care plan included using a positioning wedge and Prevalon boots which were either not used or used inappropriately. Resident identifiers: #91, #104, #151, #147, #71, and #87. Facility census: 88. Findings include: a) Resident #91 On 01/23/14, review of the care plan, with an initiated date of 01/10/14, revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications. The resident was prescribed an anti-depressant. An intervention was, Monitor for side effects and report to physician. Review of medical records revealed no evidence monitoring for side effects of [MEDICAL CONDITION] medications was being done. b) Resident #104 Resident #104's care plan, with an initiated date of 07/12/13, was reviewed on 01/23/14. The care plan revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications for for anxiety and depression. Both medications had interventions to: Monitor for side effects and report to physician. Review of medical records revealed no evidence that monitoring for side effects of [MEDICAL CONDITION] medications was being done. c) Resident #151 Review of the 01/23/14 care plan for Resident #151 revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications. The resident's current Medication Administration Record [REDACTED]. Care plan interventions for both of these medications included Monitor for side effects and report to physician. Review of medical records revealed no evidence monitoring for side effects of [MEDICAL CONDITION] medications was being done. d) On 01/23/14 at 2:00 p.m., an interview with a registered nurse, Employee #102 was conducted. Employee #102 stated there was no nursing documentation related to monitoring of the side effects of the prescribed [MEDICAL CONDITION] medications as listed in the care plan interventions for Residents #91, #104, and #151. e) Resident #147 During a Stage 1 interview, on 01/20/14 at 4:09 p.m., a white bandage was observed on the fifth (5th) finger of Resident #147's right hand. He said he had scratched it on the wheelchair rim. The resident said there was a sharp area on the rim he used to propel himself. He indicated he first noticed it at breakfast. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff was to monitor the resident for skin tears and bruising for increased bleeding. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. No indication of skin impairment was evident in the medical record. Further review of the medical record, on 01/22/14 at 1:01 p.m revealed no order for treatment. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. The determination of capacity, completed on 01/08/14, indicated the resident had capacity. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because it may have been related to the rust lifted. He added, I bled pretty bad. An interview with the director of nursing (DON) and executive director (ED) on 01/22/14 at 2:06 p.m. revealed they were unaware of an injury. The DON said the policy was to complete a DQI (incident report) and they would follow up with it. The DON reviewed the medical record and DQI reports. She confirmed she was unable to provide evidence the resident's skin tear had been assessed and monitored. f) Resident #71 Medical record review on 01/23/14 at 3:30 p.m., revealed Resident #71 required extensive assistance with his activities of daily living (ADL) due to immobility and reduced range of motion. Positioning aids were required, to maintain his current level of physical function. The care plan, created on 07/08/10, and most recently revised on 11/14/13, identified the resident's goal to maintain his current level of physical function. Interventions included a positioning wedge placed under his knees and between his legs with his ankles floated on a pillow roll. In addition, the care plan stated Prevalon boots were to be worn on both feet when up in a chair and not to be utilized with the positioning wedge. Random observations of the resident, on 01/21/14 through 01/23/14, found the resident up in his reclining wheelchair without the Prevalon boots on his feet. During an interview with Employee #34 (nursing assistant) on 01/24/14 at 9:30 a.m., she pulled back the resident's blanket and explained the positioning wedge that was under Resident #71's legs. In addition, she explained the Prevalon boots that were on the resident's feet while the positioning wedge was in place. Employee #5 (licensed practical nurse) reviewed Resident #71's care plan during an interview on 01/24/14 at 10:00 a.m. She stated the resident did not need both the Prevalon boots and the wedge when he was in bed. She confirmed Resident #71 was positioned in his bed with both the Prevalon boots and the positioning wedge. g) Resident #87 A review of Resident #87's care plan, conducted on 01/23/14 at 4:12 p.m., revealed specific drug side effects to be monitored for [MEDICATION NAME] (antipsychotic medication). The interventions, with an initiated date of 03/21/13, stated Monitor for side effects and report to physician. Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (extrapyramidal symptoms), weight gain, [MEDICAL CONDITION], postural [MEDICAL CONDITION], sweating, loss of appetite, [MEDICAL CONDITION]. A concurrent review of the medial record revealed no monitoring of the side effects were recorded on the Behavior Monthly Flowsheet or the Medication Administration Record [REDACTED]. In an interview with the director of nursing (DON), on 01/23/14 at 4:46 p.m., she stated there was no additional evidence the side effects had been monitored. She further stated there was a problem with monitoring side effects of medications for residents on antipsychotic medications and the system was broken. . | 2018-04-01 |
| 6259 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 309 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and policy review, the facility failed to provide the care and services to attain, or maintain the highest practicable physical,mental,and psychosocial well-being for one (1) of three (3) residents reviewed for skin integrity. A resident with impaired skin integrity was not assessed and monitored. Resident identifier: #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on the wheelchair rim. He related it had bled pretty bad, and staff put a bandage on it. The resident said the rim he used to propel himself had a sharp area on it causing the scratch. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff would monitor the resident for skin tears, and bruising for increased bleeding related to [MEDICATION NAME] therapy. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. Further review of the medical record, on 01/22/14 at 1:01 p.m. revealed no orders for treatments to the resident's skin. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. The determination of capacity, completed on 01/08/14, indicated the resident had capacity. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident. He informed her he had cut his finger on the silver part of the wheelchair because It may have been related to the rust lifted. He added, I bled pretty bad. He showed her rust areas along the rim and the taped area. He indicated staff used tape to cover the area where he cut his finger. Employee #6 told the resident she would have someone look at the wheelchair, and placed the chair by his bed. He informed the nurse he was concerned someone else might get a bigger cut than he did. An interview with the occupational therapist (OT), on 01/22/14 at 1:17 p.m., revealed she was not aware of a problem with the wheelchair. The OT confirmed therapy provided the resident with the wheelchair. She observed the tape and said it was not present when she provided Resident #147 with the wheelchair. Employee #73 (LPN) was interviewed on 01/22/14 at 2:07 p.m. She revealed vital signs were obtained, the physician and family were notified, a DQI (incident report) was completed, and an SBAR (change in condition note) was completed for a change in condition or with an incident/accident. She said staff would Monitor and continue charting for a certain number of days. The LPN also said staff would note the response to care in the medical record. An interview with director of nursing (DON) and executive director (ED), on 01/22/14 at 2:06 p.m.,revealed they were unaware of an injury or problem with the wheelchair. The DON confirmed the policy was to complete a DQI and the facility would follow up with it. The director of nursing reviewed the progress notes and DQI reports and said no information was available. She also reviewed the medical record and confirmed no information was available related to treatment of [REDACTED]. Review of the clinical health status/change of condition guideline, on 01/22/14 at 2:46 p.m. revealed the process for identification of change of condition included gathering of objective data and documenting assessment findings, resident response, physician and family notification. Communication both written and verbal, and was to include a concise statement of the problem, pertinent and brief information related to the situation, subjective and objective assessment of condition, nurse's assessment of the situation, recommendation or action needed to correct the problem. Another interview with the DON on 01/24/14 at 9:50 a.m., confirmed the resident's condition was not assessed, monitored, treated, and evaluated in accordance with standards of practice and the facility policy. | 2018-04-01 |
| 6260 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 323 | D | 0 | 1 | 4OKO11 | Based on medical record review, staff interview, resident interview, and observation, the facility failed to ensure the residents environment was as free from accident hazards as was possible for one (1) of three (3) residents reviewed with impaired skin integrity. A resident alleged an injury from a defective wheelchair. The chair had rusted causing sharp areas on the wheel utilized for self-propelling. Resident identifier: Resident #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on a sharp area on the wheelchair rim he used to propel himself. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because It may have been related to the rust lifted. He added, I bled pretty bad. He showed her rust areas along the rim. He also showed her a taped area, which he said staff used to cover the area where he cut his finger. She told the resident she would have someone look at it, and placed the chair back at the lower side of his bed. He informed the nurse he was concerned someone else may get a bigger cut than he did. An interview with the occupational therapist (OT), on 01/22/14 at 1:17 p.m., indicated she was not aware of a problem with the wheelchair. The OT said therapy provided the chair to the resident. She observed the tape and said it was not there when the chair was given to the resident. She looked at the chair and acknowledged rust along the silver area of the chair. Incident and accident reports were reviewed on 01/22/14 at 1:46 p.m. They revealed no evidence a report had been completed to identify or evaluate hazards or risks associated with the wheelchair. An interview with the therapy program director, a physical therapist (PT), on 01/24/14 at 9:30 a.m., revealed the wheelchair was removed from use. She said it was going to be sent to the shed. The PT indicated the maintenance department had not looked at the wheelchair yet, but she did not think it was going to be able to be fixed, and the part would have to be replaced. During an interview with the director of nursing (DON) and executive director (ED) on 01/23/14 at 9:30 a.m., they confirmed a DQI (incident report) report had not been completed, which did not allow for further analysis of risks associated with use of the wheelchair. There was no evidence the wheelchair had been periodically inspected to ensure it was in good condition. | 2018-04-01 |
| 6261 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 328 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, resident comment, and staff interviews, the facility failed to ensure a resident with a gastrostomy tube received proper treatment and care. A nurse administered a resident's medication through his gastrostomy tube using ice water. Resident identifier: #92. Facility census: 88. Findings include: a) Resident #92 During an observation of medication administration, on 01/22/14 at 3:31 p.m., Employee #73, a licensed practical nurse (LPN) poured the medication [MEDICATION NAME] sulfate 325 milligrams (mg), crushed it, and placed it in a cup. She poured water from the pitcher into the cup to mix the medication. She poured an additional cup of water from the same pitcher. The LPN carried both cups into the room and set them on the bedside stand. She administered the medication via the resident's enteral tube, utilizing the water she had poured from the pitcher. When she first flushed the tube with the water, the resident startled, and his eyes widened. Upon inquiry, the resident said he was okay. An interview with Employee #73 (LPN), on 01/22/14 at 4:45 p.m. confirmed she used ice water to administer the medication and flush the feeding tube. She said she should have used tap water. (Putting the ice water through the tube did not allow warming of the water as would happen if the resident had swallowed the water and it had warmed while passing through the esophagus before reaching the stomach.) Review of the facility's medication administration competency check list for enteral tubes, on 01/22/14 at 4:00 p.m., revealed medications were to be administered with warm water. Review of the pharmacy enteral tube medication administration, on 01/23/14 at 4:30 p.m., also indicated warm water was to be utilized. During an interview with the director of nursing (DON) on 01/22/14 at 4:50 p.m., she confirmed the standard of practice was not followed; and the nurse incorrectly administered the medication to Resident #92. | 2018-04-01 |
| 6262 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 329 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review the facility failed to ensure three (3) of five (5) Stage 2 quality insurance survey sample residents reviewed for unnecessary medications, were free of unnecessary medications. The facility failed to identify nonpharmacological interventions for residents prescribed [MEDICAL CONDITION] medications, failed to monitor for adverse effects of medications and failed to identify the wrong reason for medication administration on a physician order. Resident identifiers: #104, #149, #87, and #22. Facility census: 88. Findings Include: a) Resident #104 Review of medical records, on 01/23/14, revealed Resident #104 received [MEDICATION NAME] and [MEDICATION NAME] for depression,[MEDICATION NAME], and [MEDICATION NAME] for anxiety. Continued review, of Resident #104's medical records, failed to find evidence the facility attempted to implement non-pharmacologic interventions or explore any underlying causes of distressed behavior before administering a psychopharmacologic medication. Employee #102 provided the Behavior Monthly Flow Sheets for the last three (3) months. These flow sheets were completed by the licensed nursing staff each shift. These documents listed the medications and the reason the medication was prescribed. The Behavior Monthly Flow Sheet did not list non-pharmacological interventions specific to Resident #104 and revealed no evidence of monitoring the resident for side effects of the medications. This was confirmed by Employee #102 on 01/23/14 at 2:00 p.m. b) Resident #149 Review of the medical record, on 01/23/14 at 8:23 a.m., revealed Resident #149 was admitted to the facility on [DATE] for rehabilitation services. His admission orders [REDACTED]. The medication orders included an order for [REDACTED]. The Medication Administration Record [REDACTED]. Resident #149 received the [MEDICATION NAME] daily between 01/17/14 and 01/23/14. [MEDICATION NAME] is given for [MEDICAL CONDITION] reflux and depression may be a side effect of the medication for some individuals. During an interview with Employee #23 (director of nursing services) on 01/23/14 at 1:20 p.m., she agreed the [MEDICATION NAME] order contained the wrong indication for use and stated they would correct the order. c) Resident #87 A review of Resident #87's care plan, on 01/23/14 at 4:12 p.m., revealed specific drug side effects to be monitored for [MEDICATION NAME] (antipsychotic medication). The interventions, with an initiated date of 03/21/13, included, Monitor for side effects and report to physician. Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (extrapyramidal symptoms), weight gain, [MEDICAL CONDITION], postural [MEDICAL CONDITION], sweating, loss of appetite, [MEDICAL CONDITION]. A concurrent review of the medial record found no evidence of monitoring of the side effects on the Behavior Monthly Flowsheet or the Medication Administration Record [REDACTED]. In an interview with the director of nursing (DON), on 01/23/14 at 4:46 p.m., she stated there was no additional evidence the side effects had been monitored. She further stated there was a problem with monitoring side effects of residents on antipsychotic medications and the system was broken. d) Resident #22 On 01/22/2014 9:28 a.m., a review of Resident 22's care plan was conducted. The care plan, with an initiated date of 09/24/13, included, Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, [MEDICAL CONDITIONS] muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain. In addition, an intervention, with an initiated date of 06/11/13, was Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (extrapyramidal symptoms), weight gain, [MEDICAL CONDITION], postural [MEDICAL CONDITION], sweating, loss of appetite, [MEDICAL CONDITION]. A review of the medical record found no monitoring of the side effects on the Behavior Monthly Flowsheet or the MAR for the months of November and December 2013, and January 2014. In an interview with the director of nursing (DON), on 01/23/14 at 4:46 p.m., she stated there was no additional evidence the side effects had been monitored. She further stated there was a problem with monitoring side effects of residents on antipsychotic medications and the system was broken. | 2018-04-01 |
| 6263 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 332 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure the medication error rate was below five percent. Observation of medication administration pass identifed two (2) errors in the thirty (30) opportunities observed. This resulted in an error rate of 6%. A resident's blood pressure and pulse were not obtained for a resident as required by the physician's orders [REDACTED]. Resident identifiers: #106 and #144. Facility census: 88. Findings include: a) Resident #106 Observation of medication administration was completed with Employee #11, a licensed practical nurse (LPN), on 01/22/14 at 4:40 p.m. Resident #106 was not in his room. The LPN went down the hallway to find the resident. The nurse returned to the cart and the resident propelled himself up the hallway to the medication cart. The LPN poured the medications and administered them to the resident. Vital signs (VS) were not taken at that time. Review of the physician's orders [REDACTED]. Review of vital signs through 01/23/14 noted the last blood pressure taken was dated 01/21/14. Review of the Medication Administration Record [REDACTED]. Additionally, the progress notes were reviewed and revealed no evidence vital signs were obtained prior to administering the medication. An interview with the director of nursing (DON),on 01/23/14 at 1:00 p.m., confirmed no evidence was available to indicate vital signs were obtained prior to administering the medication. Review of the administration procedures for all medications, on 01/23/14 at 4:30 p.m., revealed prior to removing the medication package/container from the cart/drawer, the nurse was to check the Medication Administration Record [REDACTED]. b) Resident #144 Observation of medication administration with Employee #85, a licensed practical nurse (LPN), on 01/23/14 at 8:41 a.m., revealed [MEDICATION NAME] 100 mg (one capsule) was administered orally to Resident #144. Review of the medical record, on 01/23/14 at 11:00 a.m., revealed an order for [REDACTED]. Another interview with Employee #85, on 01/23/14 at about 11:30 a.m., confirmed she had only administered one tablet. She reviewed the physician's orders [REDACTED]. | 2018-04-01 |
| 6264 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 428 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, the pharmacist failed to identify a medication irregularity during her monthly medication review and report it the attending physician and the director of nursing. This was found for one (1) of five (5) Stage 2 sampled residents. Resident #149's admission orders [REDACTED]. Resident identifier: #149. Facility census: 88. Findings include a) Resident #149 Review of the medical record, on 01/23/14 at 8:23 a.m., revealed Resident #149 was admitted to the facility on [DATE] for rehabilitation services. His admission orders [REDACTED]. The medication orders included an order for [REDACTED]. The order stated (typed as written): Prilosec capsule delayed release 20 mg (milligrams) (Omeprazole) Give 1 capsule by mouth one time a day related to depressive disorder not elsewhere classified (311). (Prilosec is given for gastrointestinal disorders.) The medication administration record (MAR) also stated (typed as written): Prilosec capsule delayed release 20 mg (Omeprazole) Give 1 capsule by mouth one time a day related to depressive disorder not elsewhere clasiffied (311). Resident #149 received the Prilosec daily between 01/17/14 and 01/23/14. The clinical pharmacist medication regimen review summary indicated the pharmacist (Employee #104) reviewed the resident's medications on 01/17/14 and documented she had no recommendations. The facility policy titled, Medication Monitoring Medication Regimen Review, section 9.1, included in section E The consultant pharmacist's evaluation includes, but is not limited to reviewing and/or evaluating the following: 1) A written diagnosis, indication, or documented objective findings support each medication order. Part 3 of section E states: Indications for use and therapeutic goals are consistent with current medical literature and clinical guidelines. During an interview on 01/23/14 at 1:20 p.m., Employee #23 (director of nursing) reviewed Resident #149's MAR and active orders and confirmed the order for Prilosec was written incorrectly and this had not been noted by the pharmacist. | 2018-04-01 |
| 6265 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 431 | E | 0 | 1 | 4OKO11 | Based on observation, staff interview, review of manufacturer's instructions, and policy review, the facility failed to ensure medications were stored appropriately or according to pharmacy recommendations. A resident's medication was stored with stock medications, a multi dose vial was not labeled with the date opened, tuberculin serum was not refrigerated, and intravenous fluids with and without medications added were expired. This had the potential to affect more than a limited number of residents. Facility census: 88. Findings include: a) Medication Storage 1) North hall During an observation of the north hall medication room, with Employee #68, a licensed practical nurse (LPN), on 01/21/14 at 2:00 p.m., heparin lock flush belonging to a resident, was stored with stock medications. The nurse said, It shouldn't be here. Review of the south hall medication room with Employee #5 (LPN), on 01/21/14 at 2:15 p.m., found expired intravenous (IV) solutions. The IV solutions were: -- Lactated Ringers 1000 milliliters (ml), expired June 2013 -- Lactated Ringers 1000 ml, expired July 2013 -- 0.45 Normal Saline (NS) 1000 ml, expired June 2013 -- 0.9% (percent) Sodium Chloride (NaCl) attached to piperacillin/tazopactum (an antibacterial agent) 50 ml x 5 doses, expired December 2013 -- 0.9% NaCl 50 ml with meropenem (an antibiotic) expired October 2013 0.9% NaCl 50 ml with cefepime (an antibiotic) x 2 doses expired December 2013 0.9% NaCl 50 ml with Rocephin (an antibiotic) expired December 2013 0.9% NaCl 50 ml with Rocephin expired July 2013 0.9% NaCl 50 ml with Rocephin expired August 2013 Additionally, the pharmacy label was removed from one bag of 0.9% NaCl 50 ml with meropenum. Employee #5, (LPN) said the pharmacy representative reviewed the medications in September. She said the pharmacy came in Labor Day. The LPN also related the medications and intravenous fluids were to be checked monthly. 2) South hall Review of the south hall medication cart 2, with Employee #11 (LPN) on 01/22/14 at 3:00 p.m., found an open multi-dose vial of tuberculin serum in the cart. It was not labeled with the date opened or an expiration date, and had no indication of when it was received from the pharmacy. Employee #11 said the vial was to be dated when opened, and added, I wouldn't use it. According to manufacturer's recommendations, this should be discarded 30 days after the vial is entered. The manufacturer's instructions for storage and handling also include PPD solution must be kept refrigerated at 36 degrees to 46 degrees Fahrenheit. b) An interview with the director of nursing (DON), on 01/22/14 at 3:15 p.m., revealed the pharmacy was to check the medication/IV solutions monthly. Upon inquiry, she said the pharmacist completed an inspection and made recommendations monthly. On 01/23/14 at 3:50 p.m., medication safety systems assessments, completed by the pharmacist, were reviewed for the months of November and December 2013, and January 2014. The issues identified by the pharmacist included, but were not limited to: medication stored without a label, multi dose vial not dated, and expired medications. Review of the medication storage guidelines, on 01/22/14 at 2:52 p.m., revealed all medications dispensed by the pharmacy were stored in the container with the pharmacy label; medications labeled for individual residents were stored separately from floor stock medications when not in the medication cart; out dated medications were to be secured and immediately removed from inventory; medications requiring refrigeration were kept in a refrigerator; and once opened multiple dose vials required an expiration date shorter than the manufacturers' expiration date. The guidelines indicated, once the seal was broken, a date opened sticker would be placed on the vial, with a new expiration date of 30 days, unless otherwise directed. Additionally, review of the medication destruction policy revealed unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed. During an interview with the executive director (ED), assistant director of nursing (ADON), and director of nursing (DON), on 01/24/14 at 10:45 a.m., they acknowledged a systems failure related to medication storage. They confirmed no plan was in place to correct the ongoing issues related to expired medication, dating and labeling medications, and medications without pharmacy labels. | 2018-04-01 |
| 6266 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 441 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and review of infection control organism reports, the facility failed to maintain an infection control program to provide a safe, sanitary environment, and to help prevent the development and transmission of disease and infection. The infection control program did not conduct surveillance and investigate identified organisms in the facility in order to attempt to identify possible transmission of organisms from one resident to another. This practice had the potential to affect more than a limited number of residents residing in the facility. In addition, staff failed to adhere to posted contact precautions by not wearing personal protective equipment (PPE) during an observed dressing change. This was true for one (1) resident of the one (1) dressing change observed. Resident identifier: #99. Facility census: 88. Findings include: a) Infection Control Program On 01/23/14 at 9:00 a.m. a review of the infection control program and reports was conducted. During this review of the available reports, for August, September and October 2013, revealed a Query Summary Report from the local area hospital conducting the facility's culture and sensitivity laboratory reports. August reports revealed the following organisms: -- [MEDICATION NAME] faecium (2) -- Proteus mirabilis September reports revealed the following organisms: -- [DIAGNOSES REDACTED] Pneumoniae -- Morganella morganii -- Proteus mirabilis -- Escherichia coli October reports revealed the following organisms: -- [MEDICATION NAME] faecium -- Escherichia coli (3 residents) -- Pseudomonas aeruginosa -- Providencia stuartii An additional report, titled Golden Living Center Infection Control Committee Meeting Minutes for August, September and October 2013, was reviewed at this same time. This report did not identify any of the above organisms present in the facility during these months. On 01/23/14 at 9:55 a.m., an interview with the infection control nurse/nurse educator. A review of the Query Summary Report and the Golden Living Center Infection Control Committee Meeting Minutes was conducted. The infection control nurse/nurse educator stated she did not realize the organisms were reported on the Query Summary Report and these organisms were not identified on the report. She further agreed she did not track these organisms for a possible transmission from one resident to another. In addition, during this interview, when asked about the Plan noted on the infection control minutes, the infection control nurse/nurse educator stated she had provided inservices regarding handwashing and infection control measures during med (medication) pass during orientation, but was not able to provide an evidence of monitoring of handling of linen and other potentially infectious materials by staff and treatment observations. An interview with the administrator (NHA) was conducted. The NHA was informed of the review of the infection control reports and minutes and he stated we dropped the ball on this. He further stated he recognized this issue was brought to the Quality Assurance and Assessment (QAA) committee and nothing was happening with the reports. b) Resident #99 Medical record review on 01/22/14 at 08:30 a.m., revealed Resident #99 was placed in contact isolation on 01/13/14 for a [DIAGNOSES REDACTED]. The physician order, written on 01/13/14, was Contact isolation every shift for ESBL. Resident #99's room was identified as an isolation area with an isolation cart outside the doorway and a contact isolation sign hung on the door. Random observations on 01/21/14 and 01/22/14 verified the staff did not gown or glove upon entering the room. During wound care observation on 01/22/14 at 1:25 p.m., Employee #21 (licensed practical nurse) was observed performing a dressing change with clean gloves and no gown. Her scrub suit and the facility key ring were in direct contact with the resident's bed linen as the nurse reached across the bed. During a follow up interview, on 01/22/14 at 2:15 p.m., LPN #21 acknowledged Resident #99 was on contact isolation and she should have had a gown on when entering his room and performing his dressing change. Registered nurse #12 (director of clinical education and infection control) provided the facility's infection control policy for contact isolation during an interview on 01/22/14 at 1:57 p.m. She verified Resident #99 was on contact isolation for ESBL and all staff members should wear gowns when entering the room and caring for the resident as their policy states. The facility policy titled Isolation - Categories of Transmission - Based Precautions, included in part d of the section titled Gown (1) Wear a disposable gown upon entering the Contact Precautions room or cubicle. (2) . do not allow clothing to contact potentially contaminated environmental surfaces. | 2018-04-01 |
| 6267 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 514 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the clinical health status/change of condition guideline, and staff interview, the facility failed to ensure the accuracy of the medical record for one (1) of three (3) residents reviewed for impaired skin integrity. The medical record did not reflect the status of an accident with injury. Resident identifier: #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on the wheelchair rim. The resident said the rim he used to propel himself had a sharp area on it. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff was to monitor the resident for skin tears and bruising for increased bleeding. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. No indication of skin impairment was evident. Further review of the medical record, on 01/22/14 at 1:01 p.m. revealed no order for treatment. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because it may have been related to the rust lifted. He added, I bled pretty bad. An interview with director of nursing (DON and executive director (ED), on 01/22/14 at 2:06 p.m.,revealed they were unaware of an injury or problem with the wheelchair. The DON said the policy was to complete a DQI (incident report) and the facility would follow up with the problem. The DON reviewed the progress notes and DQI reports and said no information was available. She also reviewed the medical record and confirmed it was incomplete. An interview with Employee #73 (LPN) on 01/22/14 at 2:07 p.m., revealed vital signs are obtained, the physician and family are notified, a DQI is completed, and an SBAR (change in condition note) is completed. She said staff was to monitor and continue charting for a certain number of days. The LPN said staff would note the response to care in the medical record. Review of the clinical health status/change of condition guideline, on 01/22/14 at 2:46 p.m., revealed the process for identification of change of condition included gathering of objective data and documenting assessment findings, resident response, physician and family notification. Communication, both written and verbal, and was to include a concise statement of the problem, pertinent and brief information related to the situation, subjective and objective assessment of condition, nurse's assessment of the situation, recommendation or action needed to correct the problem. An interview with the DON on 01/24/14 at 9:50 a.m., confirmed the clinical record was not maintained in accordance with accepted professional standards. The record did not provide an accurate picture of the resident's status, including assessment and treatment of [REDACTED]. | 2018-04-01 |
| 6268 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 520 | F | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the Quality Assessment and Assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The facility failed to address deficiencies identified during pharmacy audits which included improper storage and labeling of medications, and expired medications. The facility failed to identify, monitor and track infections and there were no audits in place to evaluate isolation precaution practices. This had the potential to affect all residents. Facility census: 88. Findings include: a) The medication safety system assessments were reviewed for the months of November 2013, December 2013, and January 2014 on 01/23/14 at 3:50 p.m. Deficiencies identified by the pharmacist included: medication stored without a label, a multidose vial not dated, and expired medications. An interview was conducted with Employee #37 (executive director), Employee #149 (assistant director of nursing), and Employee # 23 (director of nursing) on 01/24/14 at 10:45 a.m. They reported there was no plan of correction in place to correct the ongoing issues related to the improper storage and labeling of medications or the presence of expired medications. On 01/24/14 at 11:00 a.m., Employee #37 (executive director and QAA Contact Person) reported the QAA committee had stopped performing audits six (6) months ago after completing a mock survey. The QAA committee reviewed resident care areas including activities of daily living, pressure ulcers, infections, incontinence, catheter care, pain, psychiatric medication use, behaviors, falls, elopement, [MEDICATION NAME] and grievances monthly. The committee was aware of the pharmacy audit results for November 2013, December 2013, and January 2014, which included improper storage and labeling of medications and the presence of expired medications within the current resident stock supplies, however a plan of action was not created to correct the deficiencies. b) The infection control program did not conduct surveillance and investigate identified organisms in the facility in order to attempt to identify an outbreak. A review of the available reports, August, September and October 2013, revealed a Query Summary Report from the local area hospital conducting the facilities cultures and sensitivity laboratory reports. August reports revealed the following organisms: [MEDICATION NAME] faecium (2), and Proteus mirabilis. September reports revealed the following organisms: [DIAGNOSES REDACTED] Pneumoniae, Morganella morganii, Proteus mirabilis, and Escherichia coli. September reports revealed the following organisms: [MEDICATION NAME] faecium, Escherichia coli (3 residents), Pseudomonas aeruginosa, and Providencia stuartii. An additional report, titled Golden Living Center Infection Control Committee Meeting Minutes for August, September and October 2013, was also reviewed. This report did not identify any of the above organisms present in the facility during these months. On 01/23/14 at 9:55 a.m., Employee #12 (infection control nurse/nurse educator) stated she did not realize the organisms were reported on the Query Summary Report and these organisms were not identified on the Golden Living report. She acknowledged she did not track these organisms for possible indications of transmission to other residents. In addition, when asked about the Plan noted on the infection control minutes, the infection control nurse/nurse educator was not able to provide any evidence of monitoring infections or staff compliance with isolation practices. On 01/24/14 at 11:00 a.m., Employee #37 (executive director and QAA Contact Person) reported the QAA committee had stopped performing audits six (6) months ago after completing a mock survey. The QAA committee reviewed resident care areas including activities of daily living, pressure ulcers, infections, incontinence, catheter care, pain, psychiatric medication use, behaviors, falls, elopement, [MEDICATION NAME] and grievances monthly. He acknowledged the infection reports and minutes were reviewed at the QAA committee meeting but no action plans were discussed or put into place. | 2018-04-01 |