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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6042 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 161 | E | 0 | 1 | R3PM11 | Based on record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover the highest daily balance of the resident trust fund for February 2014. This had the potential to affect all 117 residents with a resident trust fund account. Facility census: 135. Findings include: a) On 03/24/14 at 3:00 p.m., review of the resident funds on deposit found the highest daily balance, according to the Account Summary for February 2014, balance was $69,988.73 on 02/07/14. The facility's current surety bond was for $60,000.00. The bond was insufficient to cover the resident trust fund accounts of the one hundred seventeen (117) residents who had a trust account with the facility. b) On 03/24/14 at 3:30 p.m., an interview was completed with Employee #152 (Business Office Manager), she acknowledged the daily balance on 02/07/14 of $69,988.73 had exceeded the amount of the current surety bond. | 2018-05-01 |
| 6043 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 272 | D | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident's comprehensive assessment accurately reflect the resident's medications, one of the required elements for the comprehensive assessment. Resident #46's comprehensive minimum data set (MDS) assessment did not identify the resident was receiving an antidepressant. This was found for one (1) of nineteen (19) Stage 2 residents. Resident identifier: #46. Facility census: 135. Findings include: a) Resident #46 During record review, on 03/18/14 at 1:30 p.m., it was revealed that Resident #46 had an order dated 01/31/14, for [MEDICATION NAME], an antidepressant, 30 milligrams (mg) orally each day. The last comprehensive assessment, with an assessment reference date (ARD) of 02/06/14, made no reference to the use of the antidepressant ([MEDICATION NAME]). On 03/26/14 at 4:00 p.m., the director of nursing (DON) reviewed the January and February 2014 physician's orders [REDACTED].#46 had a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The DON verified an antidepressant should have been coded on the MDS, with an ARD of 02/06/14. A correction MDS was completed. | 2018-05-01 |
| 6044 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 279 | D | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans based on assessments of the resident's condition in regard to [DIAGNOSES REDACTED].#46 and urinary incontinence for Resident #234. This was true for two (2) of nineteen (19) Stage 2 residents. Resident identifiers: #46 and #234. Facility census: 135. Findings include: a) Resident #46 A record review, performed on 03/18/14 at 1:30 p.m., found current MEDICATION ORDERS FOR [REDACTED]. On 03/26/14 at 3:30 p.m., review of the resident's care plan found it did not address the resident's needs associated with these conditions. There were no plans developed for the issues associated with diabetes, anxiety, or [MEDICAL CONDITION]. The care plan also did not address the potential adverse effects of the medications used to treat the [DIAGNOSES REDACTED]. At 3:40 p.m. on 03/26/14, this was discussed with the director of nursing who agreed the issues associated with the [DIAGNOSES REDACTED]. b) Resident #234 Medical record review, completed on 03/26/14 at 3:45 p.m., revealed the minimum data set (MDS), with an assessment reference date (ARD) of 12/19/13, reflected the resident was occasionally incontinent. The MDS, with an ARD of 02/12/14 indicated the resident's urinary continence had changed to frequently incontinent. The care plan, developed on 12/19/13 and revised on 02/19/14, did not address urinary continence. The care plan did not provide any interventions to prevent further decline in urinary continence for this resident. In an interview with Employee #75 (registered nurse/assessment coordinator), on 03/26/14 at 5:25 p.m., she verified bladder incontinence had not been addressed on the current care plan. | 2018-05-01 |
| 6045 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 309 | D | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical well-being for one (1) of three (3) Stage 2 residents reviewed for hospitalization after admission. The facility failed to obtain physician ordered laboratory work required to monitor the resident's use of antocoagulant medication. The resident subsequently required hospitalization due to [MEDICAL CONDITION] of the left lower extremity. Resident identifier: #31. Facility census: 135. Findings include: a) Resident #31 A review of the medical record, on 03/24/14 at 4:00 p.m., revealed this [AGE] year old resident was admitted to the facility on [DATE] from an acute care hospital. The hospital's admission history and physical (H&P), dated 12/06/13, revealed Resident #31 had slight weakness on the left side, and a possible [MEDICAL CONDITION]. The resident also had chronic venous stasis and [MEDICAL CONDITION] of her left lower extremity. The H&P also noted the resident was on [MEDICATION NAME] with a therapeutic INR. The INR result was 2.89 on 12/06/14. (PT/INR ([MEDICATION NAME] time and international normalized ratio) is a lab test used to monitor bleeding and clotting time for those who are on anticoagulation therapy, such as with [MEDICATION NAME]. The therapeutic range of the INR is between 2.0 and 3.0.) The hospital's discharge summary, dated 12/10/14, indicated the primary [DIAGNOSES REDACTED]. Another discharge [DIAGNOSES REDACTED]. A PT/INR at the hospital on [DATE] showed an INR value of 1.69. Initial physician's orders [REDACTED]. A registered nurse completed a situation background assessment recommendation (SBAR) on 12/29/14 at 1:45 p.m. The nurse stated (typed as written) Resident d/t (due to) have PT/INR on 12/17/13. Lab slip not filled out and lab was not drawn. Resident on ATB (antibiotic) therapy. She notified the physician who then gave orders for an immediate PT/INR. The INR was 1.08. The physician increased the daily dose of [MEDICATION NAME] to 5 mg daily, and ordered a repeat PT/INR on 01/01/14. On 01/01/14 the INR was only 1.19. The physician increased the daily dose of [MEDICATION NAME] to 6 mg daily, and ordered a repeat PT/INR on 01/03/14. The INR was 1.32 on 01/03/14. The physician increased the daily dose of [MEDICATION NAME] to 6.5 mg. daily, and ordered a repeat PT/INR on 01/06/14. Review of nursing notes, dated 01/04/14 at 10:25 p.m., found a change in the resident's condition. Registered nurse Employee #69 assessed a discoloration to the resident's left lower extremity (LLE). The LLE was (typed as written) blue in color from ankle to just below knee, foot was of normal color, pedal pulse was faint, pt (patient) did have +3 [MEDICAL CONDITION] present. (The doctor) was notified of findings. The resident was transported to the local hospital by emergency medical services. The resident was admitted to the hospital for a [MEDICAL CONDITION] of the LLE. She returned to the facility on [DATE]. The INR on the day of discharge from the acute care facility was 2.34. | 2018-05-01 |
| 6046 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 332 | D | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, pharmacist interview, review of Centers for Medicare Services (CMS) guidance to surveyors, information from the Federal Drug Administration (FDA), and information from the National Institutes of Health (NIH), the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. The facility had a medication error rate of 5%. Resident #11 received antibiotic eye drops without sufficient contact time allowed between drops. Resident #114 was not instructed to rinse her mouth after receiving an inhaler. Two (2) of nine (9) residents were affected. Resident identifiers: #11 and #114. Facility census: 135. Findings include: a) Observation of medication administration pass, on 03/17/14 at 4:00 p.m., 03/19/14 at 8:00 a.m., and 03/20/14 at 7:00 a.m., identified 36 opportunities for medication errors. There were two (2) medication errors observed in the thirty-six (36) opportunities for error. b) Resident #11 On 03/17/14 at 4:10 p.m. a licensed nurse Employee #2 was observed as she administered two (2) drops of an antibiotic eye medication ([MEDICATION NAME]) into each of Resident #11's eyes. She administered the drops in quick succession, with only a few seconds between each instilled eye drop. An interview was conducted with the director of nursing (DON) on 03/25/14 at 12:20 p.m. She said there should be a timed interval between a first and a second dose of an eye drop. She said the drops were not to be given in quick succession, although she was unsure of the exact time interval involved. Later, at 3:10 p.m., she said she was unable to find a policy regarding how close to space two (2) eye drops if they were the same medication. The pharmacist was interviewed on 03/25/14 at 12:30 p.m. He provided his pharmacy's policy guideline related to instillation of eye drops. His interpretation of the guideline was that three (3) to five (5) minutes must elapse between each eye drop instilled into one (1) eye. He said this was regardless of whether it was the same medication, or two (2) different medications. Patient education compiled by the National Institutes of Health (NIH), related to how to instill eye drops, was reviewed on 03/25/14 at 1:00 p.m. The NIH recommended waiting at least five (5) minutes between each drop of the same medication instilled into one (1) eye. According to the Centers for Medicare Services (CMS), Sufficient contact time for eye drops. The eye drop must contact the eye for a sufficient period of time before the next eye drop is instilled. The time for optimal eye drop absorption is approximately 3 to 5 minutes. b) Resident #114 A licensed nurse (Employee #32) was observed on 03/20/14 at 7:50 a.m. as she administered a corticosteroid inhaler ([MEDICATION NAME]) to Resident #114. The nurse did not instruct the resident to rinse her mouth with water, then spit out the water, after the resident inhaled the steroidal medication. As a result, the resident did not rinse and spit after she inhaled the medication. The Federal Drug Administration (FDA) states that failure to rinse the mouth after using an inhaler may place a resident at risk for developing oral yeast overgrowth which is often referred to as thrush. On 03/25/14 at 12:20 p.m., the DON agreed that when [MEDICATION NAME] inhalers were administered, the resident should rinse his/her mouth with water and spit afterward. At 12:30 p.m. on 03/25/14, the pharmacist said that when a [MEDICATION NAME] inhaler was administered, the pharmacy's guideline includes having the patient to rinse the mouth and spit afterward. | 2018-05-01 |
| 6047 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 356 | B | 0 | 1 | R3PM11 | The facility failed to ensure the posted nurse staffing data was completed and available for viewing by the residents and/or visitors. The total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were not posted for day shift in Building 1. This had the potential to affect more than a limited number of residents and/or visitors. Facility census: 135. Findings include: a) The completion of the initial tour of building one (1) of the facility took place on 03/17/14 at 12:15 p.m. Observations at and near the nurses' station revealed the facility had not posted the staffing numbers for day shift on 03/17/14. An interview with Employee #119 (nursing supervisor) and Employee #25 (assistant director of nursing) revealed the facility had not posted the required staff posting for 03/17/14 day shift. They said the employee who normally completed the posting was not working on 03/17/14. The nurses went on to say that no other employee had completed this posting on 03/17/14. | 2018-05-01 |
| 6048 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 371 | E | 0 | 1 | R3PM11 | Based on observation, staff interview, and policy review, the facility failed to store food in a sanitary manner in the clean utility room refrigerator in Building 2. This practice had to potential to affect more than a limited number of residents. Facility census: 135. Findings include: a) A tour was conducted of the facility on 03/17/14 at 1:15 p.m. At 1:30 p.m. the refrigerator was examined in Building 2's clean utility room. There was a piece of cake wrapped in foil with a label on it stating (Resident name) 1-19-14 and a soggy sandwich wrapped in cellophane and in a brown paper bag that was unlabeled. Employee #42 (registered nurse) stated the facility practice was to throw the residents' food away after one (1) week. She discarded both items at 2:00 p.m. She also said the nurse supervisors on the afternoon shift were in charge of monitoring food dates in the resident refrigerators. This matter was discussed with the dietary manager at 10:30 a.m. on 03/19/14. She said nursing was responsible for all resident personal food items in the clean utility refrigerators. During an interview with the director of nursing (DON), at 4:39 p.m. on 03/19/14, she agreed the food needed to be discarded and provided a policy for Storage of Food dated 04/07/06. This policy included, Store potentially hazardous foods under refrigeration . for a maximum of 7 days and discard food when use-by date is unclear. The DON also said the facility practice was for nurses to monitor refrigerators with resident food items in the facility. | 2018-05-01 |
| 6049 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 425 | E | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Centers for Disease Control guidelines, and staff interview, the facility failed to implement procedures for the disposition of expired medications. Observation of the medication storage areas revealed vials of expired tuberculin testing serum, insulin and influenza vaccine. This had the potential to affect more than an isolated number of residents. Resident identifier: #45. Facility census: 135. a) Resident #45 During an observation of the A Wing medication cart, on 03/17/14 at 1:05 p.m., one (1) partially used vial of Humalog insulin was found for Resident #45. The vial contained a date to discard on 01/25/14. It was nearly empty, and had not been discarded. A licensed nurse (Employee #80) acknowledged that all multi-dose vials must be dated when first opened, and discarded according to facility policy. b) Aplisol tuberculin testing serum At 1:22 p.m. on 03/17/14, the medication storage refrigerator for Building 1 was observed with Employee #119, a licensed nurse. An opened and partially used fifty (50) test vial of Aplisol was dated as having been opened on 01/30/14. This tuberculin testing serum is injected beneath the skin of residents and employees, and used as a screening test for the presence of [DIAGNOSES REDACTED]. Employee #119 said she would check to see when this vial should be discarded. The director of nursing (DON) produced storage recommendations for Aplisol on 03/19/14 at 4:30 p.m. According to the facility's policy, vials of Aplisol must be dated when opened, and any unused portion discarded after thirty (30) days. c) Flulaval influenza vaccine On 03/17/14 at 1:22 p.m., the medication storage refrigerator for Building 1 was observed with a nurse, Employee #119. An opened and partially used five (5) milliliter (ml) vial of Flulaval influenza vaccine was dated as having been initially opened on 12/31/13. This vial can provide influenza vaccinations for ten (10) people. Employee #119 said she would check to see when this vial should be discarded. On 03/17/14 at 2:25 p.m., the assistant director of nursing (ADON) Employee #25, said the influenza vaccine was supposed to have been discarded thirty (30) days after having been opened. She said she would dispose of that vial today. The DON produced storage recommendations for influenza vaccine on 03/19/14 at 4:30 p.m. According to the facility's policy vials of Flulaval influenza vaccine must be dated when opened and discarded after twenty-eight (28) days after initially opened. d) Centers for Disease Control (CDC) According to the Centers for Disease Control (CDC), once a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that opened vial | 2018-05-01 |
| 6050 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 431 | E | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of recommendations from the Centers for Disease Control (CDC), policy review, and staff interview, the facility failed to ensure medications were labeled and dated properly. Vials of insulin did not contain expiration dates. Two (2) of eight (8) medication carts contained expired vials of insulin. Resident identifiers: #274 and #45. Facility census: 135. Findings include: a) Resident #274 Observation of the B Wing medication cart, on [DATE] at 1:00 p.m., revealed a partially used vial of Novolog insulin. There was no date on the vial, or on the box it came in, to indicate when the insulin vial had initially been opened. Upon inquiry, registered nurse (Employee #68) said the vial should have been dated when it was first opened for use, and it had not been dated. Employee #68 said the insulin must be discarded after twenty-eight (28) days of opening. Without a date inscribed, it would not be known when this vial should be discarded. The director of nursing (DON) produced insulin storage recommendations on [DATE] at 4:30 p.m. According to the facility's policy, vials of Novolog insulin may only be used for 28 days after having been initially opened. b) Resident #45 During an observation of the A Wing medication cart, on [DATE] at 1:05 p.m., one (1) partially used vials of Humalog insulin was found for Resident #45. A partially used vial of Humalog insulin contained no date to indicate when it had first been opened. A licensed nurse (Employee #80) acknowledged that all multi-dose vials must be dated when first opened, and discarded according to facility policy. Without a date inscribed, it would not be known when this vial should be discarded. The DON produced insulin storage recommendations on [DATE] at 4:30 p.m. According to the facility's policy, vials of Humalog insulin may only be used for twenty-eight (28) days after having been initially opened. | 2018-05-01 |
| 6051 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 441 | E | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective infection control program designed to provide a sanitary environment. Nursing staff did not demonstrate safe infection control techniques when using a glucometer. Nursing staff also did not properly use personal protective equipment when caring for a resident who had an infection with multi-drug resistant organism. These practices had the potential to transmit microorganisms and infection, and could potentially affect more than a limited number of residents. Resident identifiers: #11 and #96. Facility census: 135. Findings include: a) Resident #11 On 03/17/14 at 4:07 p.m., licensed nurse (Employee #2) cleaned the hand-held, blood sugar testing machine after completing a blood sugar test on Resident #69. She cleaned the machine with a disinfectant wipe, then placed the machine directly onto the resident's bed. It laid on the bed for several minutes. The nurse picked the machine up from the resident's bed and placed it back onto the medication cart with no further cleaning. The nurse then entered the room of Resident #11. At 4:14 p.m. on 03/17/14, Employee #2 completed a blood sugar test on Resident #11 without first disinfecting the testing machine that had lain on the bed of Resident #69. This practice had the potential to transmit microorganisms from one resident to another. On 03/27/14 at 11:00 a.m., during an interview with the administrator (Employee #185) and DON, they were informed of the inadequate cleaning of a glucometer between each resident used. The DON was in agreement the nurse did not follow infection control facility practice to prevent cross contamination between each use of the glucometer. b) Resident #96 On 3/17/14 at 4:35 p.m., a nurse (Employee #176) was observed in the room of Resident #96. A sign on the resident's door alerted those who entered this resident was on contact precautions. The directions on the sign instructed those who entered to wear a gown and gloves. Employee #176 was in the resident's room at that time without gloves or a gown. She moved his over-bed table, which had been in contact with the resident's bed, and television stand to where the resident could more easily view his television while lying on his right side. Upon inquiry, Employee #176 said she did not have to gown or glove unless she had direct contact with the person. She did not wash her hands. She performed a quick hand sanitation at the door by using disinfectant from a dispenser inside the room. Employee #176 then removed a large, yellow, plastic wet floor sign from inside the room and carried it to another hall. A brief review of the medical record on 03/17/14 at 4:40 p.m. found this resident has had two (2) types of multi-drug resistant organisms - methicillin resistant staphylococcus aureus and Carbapenem-resistant [DIAGNOSES REDACTED] Pneumoniae. The physician ordered contact precautions to try to prevent the spread of microorganisms and infection. An interview was conducted with the director of nursing (DON) on 03/17/14 at 4:45 p.m. The DON said staff were supposed to put on gloves and a gown when they were in this room touching the resident or any of the inanimate objects in the room. She said the nurse should have worn gloves and gowns in this instance. The DON said she would track down the sign and make sure it was disinfected. | 2018-05-01 |
| 6052 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 469 | D | 0 | 1 | R3PM11 | Based on observation and staff interview, the facility failed to maintain an effective pest control program. During an observation, there was evidence of pest infestation in room C-9. This had the potential to affect more than a limited number of rooms. Facility census: 135. Findings include: a) Room C-9 On 03/27/14 at 2:15 p.m., the director of maintenance and the nursing home administrator verified the presence of ants in room C-9 near the heating/air unit located under the window. The director of maintenance also provided the most recent pest control log, which indicated a building perimeter spray had been completed on 02/24/14. | 2018-05-01 |
| 6053 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 520 | E | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and medical record review, it was determined the facility's quality assessment and assurance (QA&A) committee failed to identify and/or develop an effective plan of action to correct quality deficiencies in the facility's daily operations in which it did have or should have had knowledge. During the survey, from 03/17/14 through 03/27/14, it was identified the facility had an issue with infection control practices. The facility had already identified infection control issues in their QA&A committee, prior to the issues discovered during the survey. In addition, after the facility became aware critical laboratory work was not obtained for a resident. The QA&A committee failed to implement corrective actions to ensure this situation did not reoccur. Residents #96 and #31 were affected; however, the practices had the potential to affect more than an isolated number of residents. Facility census: 135. Findings include: a) Infection Control On 3/17/14 at 4:07 p.m., a licensed practical nurse (LPN - Employee #2) was observed cleaning a glucometer after completing a blood sugar test. Employee #2 laid the glucometer on a resident's bed, then picked up the glucometer and placed on the medication cart with no further cleaning. The employee then used the glucometer with another resident without cleaning the glucometer. This practice had a potential for cross contamination of the glucometer. At 11:00 a.m. on 03/27/14, during an interview with the administrator and director of nursing (DON), the DON was informed of the failure to adequately clean a glucometer between each resident. The DON was in agreement the nurse did not follow infection control practices to prevent cross contamination between each use of the glucometer. In addition, the DON stated infection control issues and monitoring of staff infection control practices was presented during the QA&A meetings. b) Resident #96 On 3/17/14 at 4:35 p.m. a nurse (Employee #176) was observed in the room of Resident #96. A sign on the resident's door alerted those who entered this resident was on contact precautions. The directions on the sign instructed those who entered to wear a gown and gloves. Employee #176 was in the resident's room at this time without gloves or a gown. She moved the resident's over-bed table, that had been next to the resident's bed, and television stand to where the resident could more easily view it while lying on his right side. Upon inquiry, Employee #176 said she did not have to gown up or glove up unless she had direct contact with the person. She did not wash her hands, but instead performed a quick hand sanitation at the door by using disinfectant from a dispenser inside the room. Employee #176 then removed a large, yellow, plastic wet floor sign from inside the resident's the room and carried it to another hall. A review of the medical record, on 03/17/14 at 4:40 p.m., found the resident had two (2) types of multi-drug resistant organisms. The physician ordered contact precautions to try to prevent the spread of microorganisms and infection. An interview was conducted with the DON on 03/17/14 at 4:45 p.m. The DON said staff were supposed to put on gloves and a gown when they were in Resident #96's room touching the resident or any of the inanimate objects in the room. She said the nurse should have worn gloves and a gowns at the time of the observation. c) Resident #31 A review of the medical record, on 03/24/14 at 4:00 p.m., revealed the resident was admitted to the facility on [DATE] from an acute care hospital. The hospital's admission history and physical (H&P), dated 12/06/13, revealed Resident #31 had slight weakness on the left side, and a possible [MEDICAL CONDITION]. The resident also had chronic venous stasis and [MEDICAL CONDITION] of her left lower extremity. The H&P also noted the resident was on [MEDICATION NAME] with a therapeutic INR. The INR result was 2.89 on 12/06/14. (PT/INR ([MEDICATION NAME] time and international normalized ratio) is a laboratory (lab) test used to monitor bleeding and clotting time for those who are on anticoagulation therapy, such as with [MEDICATION NAME]. The therapeutic range of the INR is between 2.0 and 3.0.) The hospital's discharge summary, dated 12/10/14, indicated the primary [DIAGNOSES REDACTED]. Another discharge [DIAGNOSES REDACTED]. A PT/INR at the hospital on [DATE] showed an INR value of 1.69. Initial physician's orders [REDACTED]. A registered nurse completed a situation background assessment recommendation (SBAR) on 12/29/14 at 1:45 p.m. The nurse stated (typed as written) Resident d/t (due to) have PT/INR on 12/17/13. Lab slip not filled out and lab was not drawn. Resident on ATB (antibiotic) therapy. The nurse notified the physician, who then gave orders for an immediate PT/INR. The INR was 1.08. The physician increased the daily dose of [MEDICATION NAME] to 5 mg daily, and ordered a repeat PT/INR on 01/01/14. On 01/01/14 the INR was only 1.19. The physician increased the daily dose of [MEDICATION NAME] to 6 mg daily, and ordered a repeat PT/INR on 01/03/14. The INR was 1.32 on 01/03/14. The physician increased the daily dose of [MEDICATION NAME] to 6.5 mg. daily, and ordered a repeat PT/INR on 01/06/14. Review of nursing notes, dated 01/04/14 at 10:25 p.m., found a change in the resident's condition. Registered nurse Employee #69 assessed a discoloration to the resident's left lower extremity (LLE). The LLE was (typed as written) blue in color from ankle to just below knee, foot was of normal color, pedal pulse was faint, pt (patient) did have +3 [MEDICAL CONDITION] present. (The doctor) was notified of findings. The resident was transported to the local hospital by emergency medical services. The resident was admitted to the hospital for a [MEDICAL CONDITION] of the LLE. She returned to the facility on [DATE]. The INR on the day of discharge from the acute care facility was 2.34. An interview was conducted with the director of nursing (DON) on 03/25/14 at 9:00 a.m. Upon inquiry, she said there have been no changes or corrective measures put into place following the missed lab work for this resident, to ensure no PT/INRs were inadvertently omitted for any other residents in the future. She said there had been no re-education of facility staff related to monitoring lab results for residents who were on anticoagulation therapy. The DON said the facility used a quality improvement tool whenever a resident was admitted to the hospital with [REDACTED]. The purpose of this tool was to see if there was anything they could have done differently, or that they may have missed. She provided copies of this tool related to the 01/04/14 hospitalization of Resident #31. Registered nurse (Employee #119) and Employee #165 (registered nurse) completed this tool on 01/06/14. The DON said both of these quality improvement tool reports had similar findings, neither of which addressed any blood tests. She speculated that was the reason it did not trigger to the ADON or the DON that a missed lab may have potentially contributed to a hospitalization . The resident was on antibiotics, and that also was not on the quality improvement tool report. The DON produced the 12/29/13 incident report sheet for the missed PT/INR that was due on 12/17/13. She said she did not know if a full investigation was done to see why the error occurred. An interview was conducted with the Building 1 nursing supervisor, Employee #119, on 03/25/14 at 9:20 a.m. She also said she did not recall if an investigation was done related to the missed PT/INR on 12/17/13. She stated she did not recall if there was any staff education related to ensuring PT/INR's were monitored and not missed. | 2018-05-01 |
| 6484 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 159 | D | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide one resident (#16) with a quarterly statement of his personal funds account out of four residents with concerns regarding personal funds. Findings include: Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record for resident #16 revealed that he was assessed to be cognitively intact with a Brief Interview of Mental Status score of 12 on a quarterly MDS (Minimum Data Set) assessment dated [DATE]. Further review of the clinical record revealed that resident #16 did not have capacity to make his own decisions. During an interview with resident #16 on 3/25/14 at 9:01 AM, the resident stated that he is not given a quarterly statement of his personal funds account, though occasionally the facility does tell him how much money he has in his account. He further stated that he would like to receive a copy of his quarterly statement. During an interview conducted with Business Office Assistant staff #13 on 3/26/14 at 3:01 PM, staff produced the most recent quarterly statement of the resident's personal funds account. The statement had been signed by the facility's administrator. There was no evidence that the resident had also been provided a copy of his personal funds account statement. During an interview conducted with Nursing Home Administrator staff #94 on 3/26/14 at 3:18 PM, staff stated that as the facility is the Representative Payee for the resident's finances, the administrator signs the quarterly statement on behalf of the resident. Staff stated that they would in the future provide a copy to residents for whom the facility is Representative Payee, but that they do not currently do so. | 2018-03-01 |
| 6485 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 253 | D | 0 | 1 | TPO611 | Based on observations and staff interviews, the facility failed to maintain a sanitary and orderly environment with regards to resident privacy curtains and resident room sinks. Findings Include: On 3/27/2014 at 9:10 AM an observation was completed with Environmental Supervisor #7 (ES #7) in room C6. The privacy curtain was noted to have multiple brown stains during observation on 3/24/2014 that had remained. ES #7 said that housekeeping staff would normally look at privacy curtains and clean them as necessary. Observations of sinks in resident rooms D7 and D11 were noted to be loose and easily movable. ES #7 said that he would tighten the brackets holding the sink against the wall. A follow up observation was made of both sinks on 3/27/2014 at 12:10 PM. New caulking had been placed around the sink in room D11, but the sink remained easily moveable. | 2018-03-01 |
| 6486 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 272 | D | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to comprehensively assess 1 resident (#124) with regards to side rails out of 3 residents reviewed for potential physical restraints out of 13 residents with observed with potential physical restraints in place. Findings include: Resident #124 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A side rail assessment dated [DATE] noted that Resident #124 independently uses side rails and expressed a desire for a side rail to assist with bed mobility and transfers. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] noted that Resident #124's bed rail was not used as a restraint. On 03/25/2014 at 1:22 PM, an interview was completed with Nursing Assistant #25 (NA #25) NA #25 stated that Resident #124 turns herself using the side rail. I stand beside her when she transfers out of the bed. On 03/25/2014 at 1:40 PM, an interview was completed with Nurse #70. Nurse #70 stated that Resident #124 did not have an assessment of her side rails as a potential restraint. If the IDT (interdisciplinary team) determines the resident needs a restraint, they would do the initial assessment to determine what was appropriate. Quarterly, I would review the restraint. I'm not sure who would review a restraint if it came from the hospital. The IDT reviews residents after admission for an interim care plan. An interview was completed with Nurse #97 on 03/25/2014 at 2:05 PM. Nurse #97 is a Clinical Care Supervisor (CCS). Nurse #97 said, After admission, IDT reviews the resident. If the floor nurse feels like they need a restraint, IDT reviews it. On admission, the unit charge nurse reviews the resident for restraints. The (staff) nurse fills out a nursing assessment that the RN (Registered Nurse) will complete that reviews for devices. Side rails would be reviewed on the initial assessment. There is no assessment for side rails to see if they are restraints. An interview was completed with MDS Nurse #98 on 03/25/2014 at 2:15 PM. On admission, I look for orders for restraints, I look at the resident for a restraint and I look through notes. Look at the resident for things like a lap belt. That's really the only thing that we use here. There isn't any assessment I do for devices (to determine if the device is a restraint). | 2018-03-01 |
| 6487 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 280 | E | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and record review, the facility failed to ensure that 3 residents (#8, 33, 90) out of 3 residents reviewed for participation in care planning were informed of scheduled appointments and medication changes. Findings include: Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On an annual MDS (Minimum Date Set) assessment dated [DATE], the resident scored a 13 on the Brief Interview of Mental Status which indicated the resident was cognitively intact. During interviews conducted with resident #90 on 3/24/14 and on 3/26/14, the resident stated that he is not informed of medication changes nor is he made aware of upcoming appointments. Resident #90 stated that recently he went to an appointment to get his teeth extracted and he did not know that he was going to have his teeth extracted. He added, They just yanked them out! The resident was also not aware of recent medication changes nor was he aware of ongoing treatments to his leg/foot. During an interview with licensed nursing staff #1 on 3/26/14 at 11:41 AM, staff stated that she informs the resident's daughter of medication changes and of appointments. She stated that she would not inform the resident of upcoming appointments more that 1 day in advance because the resident would forget. During an interview with certified nursing assistant staff #12 on 3/26/14 at 1:58 PM, staff stated that the resident is not forgetful with her and that he does remember what they talk about from day to day. During an interview with medical records staff #39 on 3/26/14 at 2:18 PM, staff stated that she schedules appointments with the residents but she informs the resident of the appointment on the day before the appointment but does not document this anywhere. During an interview conducted with Director of Nursing (DON) staff #92 on 3/26/14, staff stated that the facility had identified that residents were not being informed of upcoming appointments and they had instituted a plan where residents would be informed of upcoming appointments by a sticky note that staff #39 would provide to the resident. Staff #92 also stated that the nurses should be informing residents of their upcoming appointments by the nurse who administers medication as there is an appointment reminder on the MAR (medication administration record) for the three days preceding the appointment. During an interview with staff #39 on 3/26/14, staff did not mention any reminder procedures involving a sticky note. During an interview with licensed nursing staff #28 on 3/26/14, staff stated that the appointment reminder on the MAR indicated [REDACTED]. Resident # 8 was admitted to the facility on [DATE]. During an interview with Resident #8 on 3/25/2014 at 10:38 AM she stated the staff do not advise her when they make outside doctor appointments for her. She stated when the transport people come to her room to pick her up for an appointment is the first time that she is aware that she would be going out for an appointment. Further interview with the Resident #8 on 03/26/14 at 11:20 am revealed she has had a few doctor appointments lately and they did not let her know until a few minutes before she was being transported to her appointment. She said she would like to be advised when the staff have made outside doctor appointments for her and to remind her of the appointment a day or two prior to the day of the actual appointment. During an interview with Resident #33 on 03/24/2014 at 1:46 PM she revealed she is not made aware that she would be leaving the building for a doctor appointment until the transport people come to her room to get her. She stated it would be nice to know when appointments were being made for her. Interview with Staff #39 on 3/26/2014 at 11:10 AM revealed she makes the outside doctor appointments for the residents. She stated she always notifies the POA and tries to notify the residents but she does not document this anywhere. She stated often the residents do not remember even when they are told of the appointments. She verified during this interview that she did not always notify all residents when outside doctor appointments are made for them. During an interview on 03/26/14 at 11:20 AM with the DON revealed the facility had already identified a concern with the lack of residents being notified timely of outside doctor appointments. She stated Staff #39 who makes the appointments for the resident is required to advise the resident of the appointment and to give the resident a sticky note with the date and time of the appointment. When Staff #39 was interviewed on 3/26/2014 at 11:10 AM she did not speak to the fact that she was required to supply the residents with sticky note indicating there date and time of any appointments. | 2018-03-01 |
| 6488 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 282 | D | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement the accidents care plan for 2 residents (#124, 20) out of 22 residents whose care plans were reviewed. Findings include: Resident #124 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of Resident #124's medical record revealed a physician's orders [REDACTED].#124 was to be transferred with the assistance of 2 staff. Review of progress notes for Resident #124 dated 3/12/2014 revealed that a nursing assistant observed resident #124 attempting an unassisted transfer from the wheelchair to the bed. Resident #124 slide to the floor on her knees. Resident #124 was documented as saying I thought I could do it myself, but I got weak. A care plan dated 3/20/2014, noted that Resident #124 was a fall risk. Interventions included: Ask resident to demonstrate the operation of the call light q (every) shift. Alarm to chair at all times. Transfer bed to chair 2 person physical assist. On 3/25/2014 at 1:22 PM, an interview was completed with Nursing Assistant #25 (NA #25). NA #25 stated, I don't let her up by herself. I stand by when she gets up. NA#25 said that she was not aware of Resident #124 having any falls. She also stated that she can tell who needs transfer assistance by the way they sit up in bed. She said that she could also look in the electronic kiosk to see how residents are to be transferred or if the resident ever had a fall. The kiosk was reviewed with NA # 25. She found no documentation of a fall for Resident #124. I think there is a way to look at the history. I'm not sure. NA #25 reported that Resident #124 does use her call bell, but that she was not asked to demonstrate the use of the call bell each shift. On 3/26/2014 at 9:02 AM, an interview was completed with Resident #124. Resident #124 denied every having a fall. She reported that she gets out of bed with assistance. An interview was completed with NA #75 on 3/27/2014 at 8:30 AM. NA #75 stated that Resident #124 is 1 person assist for transfers. If she is having a good day, she transfers herself. NA #75 also said that she was not aware of Resident #124 having any falls since I have been here over the last two months. NA #75 reported that she does not have Resident #124 demonstrate how to use the call bell. We don't need to remind her. She doesn't have to show us how to use it. She knows, no problem. A review of Resident #124's kiosk Kardex was completed with NA #75 on 3/27/2014 at 8:35 AM. The Kardex noted that Resident #124 was to have 2 people assist with transfers. On 3/27/2014 at 8:44 AM, an interview was completed with the Director of Nurses (DON). The DON stated that there was no where for staff to sign that a resident demonstrated use of the call light. We talk to them when they come in (on admission) and make sure they can use it. Resident #20 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the clinical record revealed Resident #20 had a fall from his bed on 02/18/2014. The resident was documented he slid out of his bed onto his fall mat on the left side of the bed. Again on 03/09/2014 Resident #20 was documented to fall out of his bed with no injury noted. Review of the current fall plan of care dated 01/14/14 documented fall interventions to include a bed alarm, chair alarm, fall mats to the left side of his bed, call light in reach, and to ensure a safe environment. Observation on 3/25/14 at 4:30 PM revealed the resident was in bed with metal tube feeding pole with four large metal legs located on top of the fall mat beside the resident's bed. The mat beside the resident's bed was noted to be placed there to protect the resident from injury due to history of falling out of the bed. The fall care plan documented an intervention indicating the staff should maintain a safe environment. The placement of the large metal tube feeding pole located on top of the fall mat during this observation put Resident #20 at risk for injury due to his history of sliding out of the bed onto this mat. This observation was shared with Staff #95 on 03/25/2014 at 10:50 AM and she verified the metal pole should not be on the fall mat due to potential injury if Resident #20 should fall from the bed. The facility failed to implement Resident #20's fall care plan intervention to ensure a safe environment by placing the metal tube feeding pole on top of the fall mat located next to the resident's bed. | 2018-03-01 |
| 6489 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 315 | D | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observations, and record review, the facility failed to ensure that there was a medically justified use of a catheter for 1 resident (#124) out of 3 residents reviewed for catheters out 4 residents identified with catheters in stage 1. Findings include: Resident #124 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #124's medical record revealed a physician's orders [REDACTED]. Resident #124's care plan dated 3/20/2014 noted that she had an indwelling urinary catheter for [MEDICAL CONDITION]. Review of Resident #124's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted no urinary toileting program has been tried since admission. An interview was completed with Nurse #97 on 3/25/2014 at 2:30 PM. Nurse #97 stated she was familiar with Resident #124 and that Resident #124 was not on a toileting program. On 3/25/2014 at 2:55 PM, an interview was completed with Resident #124's physician. The physician stated, We spent a month working on an incisional abscess. We thought she was going to die. In the last 5 weeks, she is better. We should have been doing more to try and get it (urinary catheter) out. We wanted to keep the wounds on her buttocks healed. She hasn't had a (Stage) 3 or 4 (pressure ulcer). Her nutritional status was so bad, I was worried about them getting worse. We should have done more to get the urologist to see about getting it out. When she came back in January, she had a residual volume of over 300 cc (cubic centimeters). She also went to the hospital in February for the abscess. An observation was completed on Resident #124 on 3/26/2014 at 12:00 PM. Resident #124 was noted to have an indwelling urinary catheter. On 03/26/2014 at 12:40 PM, an interview was completed with the Director of Nurses (DON). The DON stated that an appointment has been made for Resident #124 to see a urologist to evaluate for the need of the catheter. | 2018-03-01 |
| 6490 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 371 | E | 0 | 1 | TPO611 | Based on interviews and observations, the facility failed to appropriately maintain food items to prevent potential food borne illness. Findings include: On 3/26/2014 at 10:50 AM, an observation of the dry storage area of the kitchen was completed. One bag of pasta and one bag of potato chips noted to be opened but not dated. There was also one bag of lasagna noodles left open to air; not resealed. On 3/26/2014 at 10:52 AM, an interview was completed with Dietary Supervisor #5 (DS #5). DS #5 said the pasta was just opened yesterday. He was observed to put the date on the bag and he threw away the potato chips. He folded the bag of lasagna noodles over to close them and left them on the shelf. On 3/26/2014 at 12:25 PM, the lasagna noodles were still noted on the shelf. | 2018-03-01 |
| 6491 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 460 | E | 0 | 1 | TPO611 | , Based on observations and interviews, the facility failed to ensure that bed privacy curtains provided full visual privacy. Findings Include: On 3/24/2014 at 9:45 AM observations of rooms were completed with Environmental Supervisor #7 (ES #7). Sampled rooms A3, A6, A13, C16, D7 and D13 noted that privacy curtains would only enclose one resident at a time for privacy. ES #7 said that he would order and install extra curtain panels to cover both residents. | 2018-03-01 |
| 6564 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 253 | E | 0 | 1 | BWIF11 | Based on observation, resident interview, and staff interview, the facility failed to provide effective housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior. The floor tiles had cracks that were filled with dirt/debris, screens on sliding glass doors were loose, draperies were not hanging properly, and tiles in one room were uneven. This had the potential to affect more than a limited number of residents. Facility census: 105. Findings include: a) A tour of the 300 hall at 10:30 a.m. on 03/19/14, revealed the following observations: -- Rooms #322 and #323 had sliding glass doors opening to an enclosed yard. The screens on the doors were hanging loose from their frames on the outside of the glass. The screens banged on the doors when the wind blew. -- Rooms #310 and #328 had curtains on the sliding doors which were hanging loose in places where they had come loose from the rail. Resident #34 in room #328, stated the drapes had been like this a long time. -- Rooms #310, #326, #335, and #328 had floor tiles with many cracks running the width of the room. The cracks were blackened, which revealed an inability to remove all soil from the cracks. In room #335 the crack in the floor tile was wider and raised on one side and spanned the width of the room. The difference in the height of the flooring had the potential to cause a person to stumble when crossing the area. These observations were relayed to Employee #117 (Maintenance worker) at 11:00 a.m. on 03/19/14. He acknowledged the floors were in bad shape and he would check room #335 and have housekeeping look at the drapes. During an interview with the Administrator at 11:10 a.m. on 03/24/14, she added the facility was in the planning stages of replacing the flooring, and acknowledged the floors posing a hazard should be repaired first. | 2018-01-01 |
| 6565 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 272 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to conduct a comprehensive assessment accurately reflecting the status of the individual resident. Resident #76's minimum data set (MDS) assessment did not identify he had no natural teeth and no dentures. Resident #132's assessment indicated the resident was on a physician prescribe weight loss program, which was incorrect. Inaccuracies of the MDSs were identified for two (2) of thirty-seven (37) sample residents reviewed during Stage 2 of the Quality Indicator Survey. Resident identifiers: #76 and #132. Facility census: 105. Findings include: a) Resident #76 On 03/18/14 at 11:30 a.m., an observation of the resident revealed this resident was edentulous (no natural teeth). The resident was unable to be interviewed due to his cognitive status. An interview was conducted with the resident's daughter by telephone on 03/18/14 at 11:45 a.m. During the interview, his daughter commented her father had dementia and had lost his dentures at home prior to his admission to the facility. On 03/26/14 at 8:30 a.m. a medical record review for Resident #76 found he was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment, dated 11/09/13, noted the resident had no dentures present and he was edentulous. Review of the significant change MDS, with an assessment reference date (ARD) of 02/28/14, found Item L0200 - Dental was not checked for B. No natural teeth or tooth fragment(s) (edentulous). Instead, L0200 was checked as Z. None of the above were present. An interview was conducted with Employee #109, the MDS Coordinator, on 03/26/14 at 12:20 p.m. After reviewing the resident's MDS, she agreed it was an incorrect assessment for the resident's dental status. She commented it should have been coded as B in L0200 for edentulous. She corrected the assessment immediately. b) Resident #132 Review of the resident's medical record, on 03/25/14 at 10:00 a.m., noted the resident's weight decreased forty-six (46) pounds (or 36.3%) between 12/09/13 and 02/26/14. The physician's progress note, dated 02/28/14, stated Resident #132's current weight loss was related to his recent leg amputation, depression, and a loss of appetite. The dietary note dated 03/07/14, stated the resident's current weight had declined 12.2%, because of a decrease in intake, his recent leg amputation, and a wound infection. Item K0300 of the significant change minimum data set (MDS) assessment, with an assessment reference date of 01/27/14, was coded 1 for Yes, on physician prescribed weight-loss regimen. An interview was conducted with Employee #109 (MDS coordinator) on 03/25/14 at 11:30 a.m. She confirmed the MDS assessment was coded inaccurately, the resident was not on a prescribed weight loss program. | 2018-01-01 |
| 6566 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 278 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the individual completing and certifying the accuracy of the assessments for two (2) of thirty-seven (37) Stage 2 sampled residents coded the assessments accurately. The minimum data set (MDS) assessment did not accurately reflect Resident #76's dental status. Resident #132's MDS was coded inaccurately for weight loss. Resident identifiers: #132 and #76. Facility census: 105. Findings include: a) Resident #132 Review of the resident's medical record on 03/25/14 at 10:00 a.m., found the resident's weight had decreased forty-six (46) pounds (or 36.3%) between 12/09/13 and 02/26/14. The physician's progress note, dated 02/28/14, stated Resident #132's current weight loss was related to his recent leg amputation, depression, and a loss of appetite. The dietary note, dated 03/07/14, stated the resident's weight had declined 12.2%, because of a decrease in intake, his recent leg amputation and a wound infection. The significant change minimum data set (MDS) assessment, with an assessment reference date of 01/27/14, was coded 1 for item K0300, which indicated the resident was on a physician prescribed weight-loss regimen. An interview was conducted with Employee #109 (MDS coordinator), on 03/25/14 at 11:30 a.m. She confirmed the MDS assessment had been coded inaccurately. Item K0300, should have been coded 2 to indicate the resident was not on a physician-prescribed weight-loss regimen. The MDS was corrected after this interview. b) Resident #76 On 03/18/14 at 11:30 a.m. an observation of the resident revealed he was edentulous. The resident was unable to be interviewed due to his cognitive status. A family interview was conducted with his daughter by telephone on 03/18/14 at 11:45 a.m. During the interview, his daughter commented he had dementia and had lost his dentures at home prior to his admission to the facility. On 03/26/14 at 8:30 a.m., review of the resident's medical record review found he was admitted on [DATE]. The admission nursing assessment, dated 11/09/13, identified the resident had no dentures present and he was edentulous. Review of the significant change MDS, with an assessment reference date (ARD) of 02/28/14, found Section L - Oral/Dental Status did not have L0200 B No natural teeth or tooth fragment(s) (edentulous) checked as applying to this resident. Instead, the section was coded at L0200 Z for None of the above were present. An interview was conducted with Employee #109, the MDS Coordinator, on 03/26/14 at 12:20 p.m. After reviewing the resident's MDS, she agreed it was an incorrect assessment for the resident's dental status. She commented it should have been coded as B in item L0200 for edentulous. She corrected the assessment immediately. | 2018-01-01 |
| 6567 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 279 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to ensure the care plans for five (5) of thirty-seven (37) residents reviewed in the sample had measurable goals and interventions developed to enable the residents to achieve the highest level of well-being the resident might be expected to attain. Resident #140 did not have a care plan established relative to his multiple contractures and his activities of daily living (ADL) needs. Residents #113, #97, and #24, did not have care plans developed when isolation precautions were implemented and/or the plan was not established timely. Resident #132's care plan did not identify the need for a specialized utensil to improve the resident's abilities to feed himself. Resident identifiers: #140, #113, #97, #24, and #132. Facility census 105. Findings include: a) Resident #140 A review of the medical record revealed Resident #140 was admitted on [DATE] after hospitalization for [MEDICAL CONDITION]. His [DIAGNOSES REDACTED]. 1) Observation of this non-verbal resident, at 3:30 p.m. on 03/17/14, revealed he was very small in stature and thin (weight: 98 pounds). He was lying in bed on a concave mattress with his legs crossed and drawn up to his body. His movements were jerky and random. During an interview with Employee #16, a licensed practical nurse (LPN) who was also a direct care giver, at 10:00 a.m. on 03/18/14, she was asked if the resident had any contractures, She replied he did, although he received no therapy and used no splints at the present time. A review of the Physical Therapy evaluation, completed on 01/06/14, revealed the resident was assessed with [REDACTED]. This was confirmed by Employee #125 (Rehabilitation Manager) at 9:45 a.m. on 03/20/14. According to the resident's comprehensive minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/08/14, the resident was identified in item G0400 as having limited functional range of motion for both of his upper extremities and both of his lower extremities. While the MDS does not trigger a care area based on the coding for G0400, the resident was identified as having limited range of motion on the MDS and was assessed by nursing and physical therapy as having contractures. This readily identifiable need was an area that required development of a care plan to prevent worsening of, and/or complications due to, the contractures. Review of the resident's care plan did not find a focus, goal, or interventions that addressed the resident's contractures. There was no plan to prevent worsening of the contractures and no plan to prevent complications associated with contractions. 2) There was a focus item for assistance with activities of daily living (ADL) care for the resident, but it only listed each function and stated the resident required total care. There were no nursing interventions to communicate to direct care staff the resident's needs for transfer, positioning, or other ADL requirements. During an interview with Employee #109 (MDS Nurse) at 11:00 a.m. on 03/25/14, she explained her responsibility for initiating the care plan was for the needs triggered by the MDS and from there the care plan became the responsibility of the nurses in direct care, but stated she would correct the care plan. b) Resident #112 1) Observation of the resident, during the initial tour on 03/17/14, and throughout the survey (through 03/27/14), revealed he was in contact isolation for [MEDICAL CONDITION] (C. diff). During an interview with Employee #4 (Infection Control Nurse) at 10:50 a.m. on 03/19/14, he was asked when the isolation was initiated. After reviewing the resident's record and the Infection Control Surveillance records, Employee #4 was unable to provide an exact date. He stated the facility policy did not require a physician's orders [REDACTED]. Further review of the physician's progress notes revealed Resident #112 tested positive for active [DIAGNOSES REDACTED] infection on 02/24/14. The resident was placed on antibiotics at that time, but the care plan stating Provide Level II Precautions was not initiated until 03/07/14. Based on the evidence available in the record and the staff interview, the initiation of the isolation into the care plan was not timely. 2) A goal was initiated for this resident on 02/12/13, for AROM (active range of motion) to the neck, support head only, NO PROM (passive range of motion), 3 days a week. A target date was set at 04/22/14. The goal was not measurable, as there was no statement of an anticipated outcome which made evaluation impossible. No interventions were identified related to this goal. c) Resident #97 A review of the Infection Control Monthly Line Listing for February 2014 revealed Resident #97 had an onset of gastrointestinal (GI) symptoms on 02/12/14. The infection was marked resolved on 02/15/14. A culture was collected on 02/15/14, which was reported Positive for Norovirus. During an interview with Employee #4 (Infection Control Nurse) at 10:50 a.m. on 03/19/14, he was asked when the isolation was initiated and discontinued. He referred to the onset and resolved dates and stated those were the dates of isolation. He had no comment regarding the fact the positive culture was collected on the day the isolation was discontinued. Employee #4 provided a physician's progress note entered into the electronic health record (EHR) on 02/13/14. The note addressed the resident's GI symptoms of vomiting and diarrhea. The note stated the assessment/plan acknowledged the implementation of precautions which included Residents will be sequestered to their rooms and will receive all meals and therapy in room until outbreak protocol has been lifted. The resident's record contained no evidence a care plan addressing the infection or the isolation interventions was ever established. d) Resident #24 A Change of Condition form, entered into the EHR on 02/14/14 by the attending physician, indicated the resident had symptoms of gastroenteritis with frequent vomiting and diarrhea. The entry also noted the facility had met criteria for a GI outbreak. The resident's wife, who occupied the same room, also had the symptoms. The Assessment/Plan included, Residents will be sequestered to their rooms and will receive all meals and therapy in room until outbreak protocol has been lifted. Review of the resident's care plan found no evidence a care plan addressing the infection or the isolation interventions were established. e) Resident #132 The resident's medical record was reviewed on 03/25/14 at 10:00 a.m. Resident #132 was admitted for rehabilitation services for left sided weakness after a second stroke. He was prescribed built up utensils to enhance his self-feeding capabilities and to prevent further weight loss. On 02/10/14 an order was written to provide the resident with built up utensils for self-feeding with every meal. The resident's current care plan lacked information regarding the use of built up utensils for self-feeding with every meal. During an interview with Employee #109 (MDS coordinator) on 03/25/14 at 11:00 a.m., she confirmed the care plan did not address the resident's need for built up utensils for self-feeding. | 2018-01-01 |
| 6568 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 280 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to periodically evaluate and revise the care plan based on changes in health care status and/or physician's orders [REDACTED]. Resident #112's and #87's care plans had interventions that were no longer appropriate due to changes in condition. Resident #132's care plan was not revised when she no longer received therapy. Resident #112's care plan was not revised to reflect isolation precautions were no long in effect. Lack of care plan revision was identified for four (4) of thirty-seven (37) Stage 2 sample residents. Resident identifiers: #112, #87, #12, and #132. Facility census: 105. Findings include: a) Resident #112 1) A review of the resident's care plan revealed an identified focus for Restorative Ambulation initiated on 06/13/13. A measurable goal was established: Patient will participate in the walk to dine program X 90 days. The 90 day evaluation would have been due 09/13/13. As of 03/25/14, there was no evidence of a 90 day evaluation. In addition, the seven (7) interventions in the active care plan were no longer applicable to the resident. All seven (7) of the interventions were directed towards ambulation. The medical record, including the comprehensive assessments, indicated the resident had been non-ambulatory since 01/25/14. All of the interventions were assigned to Restorative Nursing. There was no evidence the resident was receiving services from Restorative Nursing. When interviewed at 12:40 p.m. on 03/25/14, Employee #39 (Nurse responsible for Restorative Care) confirmed restorative care was not currently being provided to Resident #112. She could not state when it had ceased. She was aware the resident no longer ambulated, but was not sure whose responsibility it was to update the care plan or contact the physician to update the care orders. 2) The resident's care plan for activities was also reviewed. The focus of the plan was to encourage and arrange participation in group activities. Five (5) of the nine (9) interventions were directed toward meeting this goal. This plan was reviewed and updated on 03/07/14, which was the same day he was placed in isolation. There was no mention of the limitations imposed on activities by the isolation. During an interview with the Administrator at 11:00 a.m. on 03/20/14, she stated she was not aware the care plans were not being updated, and would check into this immediately. b) Resident #87 Resident #87 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #87 was observed in bed at 10:30 a.m. on 03/18/14. She was totally dependent for all activities of daily living (ADLs) and was transferred with a mechanical lift. This was confirmed by Employee #120 at 10:30 a.m. on 03/18/14, who added the resident now only received positioning interventions for comfort. A review of the active care plan for Resident #87 revealed it was not revised as the resident's health status deteriorated, to the extent that the goals in the care plan no longer were attainable and interventions were not realistic and could not be performed. The following Focus care issues were no longer appropriate: 1. Restorative Range of Motion: This problem was initiated on 12/05/12 with two (2) goals. Goal #1 stated, Patient will be able to move BUE (bilateral upper extremities) through normal range of motion, for this resident, without discomfort thru (through) next review which was set at 04/22/14. There was no evidence an evaluation was ever done, and no revisions of the plan were made. During an interview with Employee #64 (Aide) at 3:00 p.m. on 03/18/14, she stated the resident could no longer perform AROM (active range of motion) of her upper extremities and could no longer tolerate even small amounts of PROM (passive range of motion). This was confirmed by Employee #39 (Restorative Nurse) at 12:40 p.m. on 03/25/14, who added the resident was now totally fed by staff and the only other thing they were doing was positioning. Goal #2 stated, Prevent contractures . thru (through) next review and the review date was set for 04/22/14. This goal was incorrect at its inception because the November and December Rehabilitation Instruction Sheets indicated the resident had contractures already established at that time and instructed the restorative aides to use only PROM and multipodus boots in bed. There was no evidence these interventions were carried out or that the interventions were ever evaluated and reported to the physician. There were no revisions to this care plan since 12/05/12. In addition the following Focus problems had no evidence of review and revision: -- 1. Splint assistance: Resident no longer used splints. -- 2. C.Diff. (,[MEDICAL CONDITION]. difficule) infection with isolation, initiated 05/21/13 was still on the care plan although the resident was not in isolation and according to Employee #4 (Infection Control Nurse), at 2:00 p.m. on 03/24/14, the resident was clear of the infection and had only been isolated for a few weeks at the time. -- 3. Contractures of the left upper extremity was initiated on 03/18/12. No revisions of the care plan were made when the physician's orders [REDACTED]. Exercises were no longer being done. The physician indicated, in his progress notes on 03/18/14, the resident had increased pain and her care was primarily palliative. The care plan was reviewed with Employee #109 (MDS Nurse) at 3:25 p.m. on 03/25/14. She agreed the plan was no longer realistic for Resident #87. During an interview with the Administrator at 11:00 a.m. on 03/20/14, she agreed that setting a review date for a year from initiation was too long,. She confirmed the care plan should be reviewed quarterly with the care plan meetings. c) Resident #12 A review of the medical record revealed Resident #12 was an [AGE] year old male admitted to the facility on [DATE], The resident was alert and verbal, but very confused and had poor safety awareness. A review of the care plan at 3:00 p.m. on 03/18/14, revealed a Focus problem in the active care plan of gastrointestinal (GI) symptoms requiring Level II precautions (Contact Isolation) which had been initiated on 02/13/14. This resident was observed in the dining room at 2:30 p.m. on 03/17/14, at an activity. His room had no evidence of isolation precautions. During an interview with Employee #4 (Infection Control Nurse) at 10:50 a.m. on 03/19/14, he was asked if the resident was in isolation. He replied the facility had an outbreak of norovirus which lasted from 02/13/14 until 02/22/14. He said all residents exhibiting symptoms were placed in contact isolation. Resident #12 was one of those residents, but he was only in isolation for a few days. A review of the Infection Control Surveillance records for February 2014 confirmed the resident had an onset of GI symptoms on 02/13/14, which were resolved on 02/15/14 (this date was provided by Employee #4 because the date on the record was unreadable). The resident's care plan was not revised when isolation precautions were no longer needed. d) Resident #132 The resident's medical record was reviewed on 03/25/14 at 10:00 a.m. Resident #132 was admitted for rehabilitation services for left sided weakness after a second stroke. He was referred to restorative nursing after being discharged from occupational therapy on 02/18/14, and physical therapy on 02/28/14. The care plan, dated 11/01/13, stated the resident received therapy/rehabilitation Physical therapy/Occupational therapy treatment five (5) times a week. There was no revision of the care plan to reflect the change from therapy/rehabilitation to restorative nursing care. During an interview on 03/26/14 at 4:41 p.m., Employee #109 (MDS coordinator) verified the current care plan was inaccurate. The MDS coordinator confirmed the resident was in the restorative nursing program and no longer received physical and occupational therapy. | 2018-01-01 |
| 6569 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 282 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure interventions ordered by the physician, and planned in the care plan, were provided for four (4) of thirty-seven (37) residents reviewed for range of motion. Resident identifiers: #56, #12, #14, and #1. Facility census: 105. Findings include: a) Resident #56 During an interview with Employee #93, a licensed practical nurse (LPN), on 03/17/14 at 2:37 p.m., she related Resident #56 had a contracture of her knees. Review of the resident's medical record found current physician's orders [REDACTED]. The restorative notes were reviewed on 03/25/14 at 1:49 p.m. They indicated no services were provided for the month of March 2014. Employee #39 (LPN), restorative nursing supervisor, confirmed the resident had not received ROM due to staffing issues. An interview with the administrator,on 03/25/14 at 3:11 p.m., confirmed, due to staffing issues, restorative nursing had not been provided in accordance with the resident's written plan of care. b) Resident #12 A review of the medical record revealed Resident #12 was an [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He had three (3) falls within the previous two (2) months. On 06/12/13, the attending physician ordered RNP (Restorative Nursing Program): AROM (active range of motion) to BLE's (bilateral lower extremities) and Ambulation with rolling walker min (minimum) assist of 1. These orders were reflected in the resident's active care plan as interventions for the focus problem related to activities of daily living. There was no evidence the resident received these services in February or March 2014. The Restorative Care forms used to record the care were blank. During an interview with Employee # 39 (Nurse in charge of Restorative Care) at 8:50 a.m. on 03/25/14, she acknowledged the resident had not received the restorative care services as ordered and planned for in the care plan. She attributed this to low staffing. c) Resident #14 A review of the medical record of Resident #14 revealed he had been referred to Restorative Care for an exercise protocol to the right lower extremity when he was discharged from physical therapy on 12/06/13. On 03/06/13, the physician also ordered Restorative Dining program due to a significant weight loss and increased need for assistance with eating. Both of those orders remained current and were care planned. There was no evidence the resident had received restorative nursing care. During an interview with Employee #120 (Direct Care Nurse) at 10:30 a.m. on 03/18/14, she stated the resident went to dining room for meals because he needed supervision. She was not sure if he was receiving restorative care or not. When interviewed at 12:40 p.m. on 03/25/14, Employee #39, the nurse responsible for Restorative Care) stated restorative care was not being given to Resident #27 at present. She could not state when it had ceased. The forms used by the facility to document restorative care were blank for February and March 2014. She stated the resident was taken to restorative dining, but could produce no evaluation of his progress or lack of progress. Employee #39 attributed the failure to low staffing. Both she and the two (2) restorative aides were pulled almost daily to provide routine direct care. d) Resident #1 On 03/25/14 at 2:10 p.m., an interview was conducted with Resident #1 after she requested to talk with someone from the State. She stated, I have only received three (3) days of restorative therapy in the month of March because of the restorative staff being pulled to work the floor and this has been going on since December. Resident #1 further commented, This is hindering me and I have gotten worse by not getting restorative therapy. Review of the Restorative Nursing Record for January, February, and March 2014 found the restorative activities were documented as occurring on only a few occasions each month. Although the extent and actual cause of the resident's declines could not be determined, the resident felt she had declined as a result of not being provided with restorative services. | 2018-01-01 |
| 6570 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 311 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to ensure two (2) of the thirty-seven (37) sample residents received restorative services as ordered by the physician and planned in the care plan to maintain and/or improve the resident's functional abilities. Resident identifiers: #27 and #14. Facility census 105. Findings include: a) Resident #27 A review of the medical record revealed Resident #27 was admitted to the facility on [DATE], after an extended illness in an acute care facility left her very weak. Prior to her illness she was planning orthopedic surgery to correct a lower extremity deformity. She recently received her right lower extremity ankle brace and wore a modified left shoe for comfort. She was not able to ambulate without a brace. The resident had limited range of motion (contractures) in her right shoulder, left shoulder, right ankle, and left ankle. The resident was admitted for physical therapy to improve ambulation with her new brace and to increase strength and coordination, to reach her maximum potential in preparation for surgery and return home. Her assessment stated, Patient demonstrates good rehab potential for stated goals as evidenced by prior level of function, motivation to participate, motivation to return to PLOF (prior level of function) and support systems in place. Her physical therapy continued from 01/07/14 - 02/16/14. She was discharged from physical therapy on 02/16/14, with the following goal: Restorative nursing program to be established prior to discharge in order to help pt. (patient) maintain gains achieved during physical therapy services. There was no evidence the resident received restorative nursing care, although the physician also ordered the service. When interviewed at 12:40 p.m. on 03/25/14, Employee #39, the nurse responsible for Restorative Care, confirmed restorative care was not presently being given to Resident #27. She could not state when it had ceased. The forms used by the facility to document restorative care were blank for February and March 2014. Employee #39 attributed the failure to low staffing. Both she and both of the restorative aides were pulled almost daily to direct care. b) Resident #14 A review of the medical record of Resident #14 revealed he was referred to Restorative Care for an exercise protocol to the right lower extremity, after discharge from physical therapy on 12/06/13. On 03/06/13, the physician also ordered a Restorative Dining program due to a significant weight loss and increased need for assistance with eating. Both of those orders remained current and were care planned. There was no evidence the resident received restorative nursing care. During an interview with Employee #120 (Direct Care Nurse) at 10:30 a.m. on 03/18/14, she stated the resident went to dining room for meals because he needed supervision. She was not sure if he was receiving restorative care or not. When interviewed at 12:40 p.m. on 03/25/14, Employee #39, the nurse responsible for Restorative Care) confirmed restorative care was not presently being given to Resident #27. She could not state when it had ceased. The forms used by the facility to document restorative care were blank for February and March 2014. She stated the resident was taken to restorative dining, but could produce no evaluation of his progress or lack of progress. Employee #39 attributed the failure to low staffing. Both she and the two (2) restorative aides were pulled almost daily to provide routine direct care. | 2018-01-01 |
| 6571 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 318 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interview, and staff interview, the facility failed to ensure five (5) residents with limited range of motion, of the thirty-seven (37) residents in the Stage 2 sample, received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion in an attempt to maintain their highest level of function. Resident identifiers: #140, #87, #13, #56, and #1. Facility census: 105. Findings include: a) Resident #140 A review of the medical record revealed Resident #140 was admitted on [DATE], after hospitalization for [MEDICAL CONDITION]. His [DIAGNOSES REDACTED]. Observation of the resident at 3:30 p.m. on 03/17/14, revealed he was very small in stature and thin (weight: 98 pounds) and was non-verbal. Observation revealed he was lying in bed on a concave mattress with his legs crossed and drawn up to his body. His movements were jerky and random. During an interview with Employee #16 (LPN, direct care giver) at 10:00 a.m. on 03/18/14, the employee was asked if the resident had any contractures. The nurse replied the resident had contractures, although he received no therapy and used no splints at the present time. A review of the Physical Therapy evaluation completed on 01/06/14, revealed the resident was assessed with [REDACTED]. This was confirmed by Employee #125 (Rehabilitation Manager) at 9:45 a.m. on 03/20/14. A review of the care plan for Resident #140 failed to reveal a focus identified for limited range of motion or contractures. There was a focus item for assistance with activities of daily living (ADL) care, but it only listed each function and stated the resident required total care. There was no indication of the location of the contractures. No measurable goal was established to enable evaluation of progress or decline. There were no interventions regarding care to be provided relative to the resident's contractures. Resident #140 received physical therapy from 01/06/14 - 02/28/14 when services were discontinued because he reached his maximum potential. He was referred to Restorative Nursing (RNP) for safety, positioning, and skin integrity. The physician ordered RNP on 01/27/14 for passive range of motion (PROM) and on 02/28/14, added stretching protocol to the order. These orders were received by Employee #15 (restorative care aide) and entered with instructions into the RNP manual. There were no entries indicating the services were performed. When interviewed at 12:40 p.m. on 03/25/14, Employee #39, (Nurse responsible for Restorative Care) confirmed, except for positioning, restorative care was not presently being given to Resident #140. She could not state if the resident had ever received the services. The forms used by the facility to document restorative care were blank for February and March 2014. b) Resident #87 Resident #87 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #87 was observed in bed at 10:30 a.m. on 03/18/14. She was totally dependent for all ADLs and was transferred with a mechanical lift. This was confirmed by Employee #120 at 10:30 a.m. on 03/18/14, who added the resident now only received positioning interventions for comfort. A review of the physician's orders [REDACTED]., Restorative Dining, and Utilize bent built up utensils at all meals. Restorative nursing interventions were ordered by the physician and put into the care plan. Documentation revealed they were only performed six (6) times in November 2013 and two (2) times in February 2014. During an interview with Employee #64 (Aide) at 3:00 p.m. on 03/18/14, she stated the resident could no longer perform AROM of her upper extremities and no longer could tolerate even small amounts of PROM. This was confirmed by Employee #39 (Restorative Nurse) at 12:40 p.m. on 03/25/14. The nurse added the resident was now totally fed by staff, and the only other thing they were doing was positioning. There was no evidence these interventions were ever evaluated or anything reported to the physician. Several of the problems identified on the care plan included, as an intervention, to notify the physician of changes; however, the resident continued to have active orders for services that were not being done. When the medical record was reviewed on 03/24/14, it revealed an order for [REDACTED]. were still present although the resident had not consistently received Restorative care for months. During an interview with the Administrator at 11:00 a.m. on 03/20/14, she stated she was aware the RNP was not being delivered consistently. She had no answer for the orders being continued, and had no plan of action for correcting the lack of service. c) Resident #12 A review of the medical record revealed Resident #12 was an [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He had three (3) falls within the previous two (2) months. On 06/12/13, the attending physician ordered RNP (Restorative Nursing Program): AROM (active range of motion) to BLE's (bilateral lower extremities) and Ambulation with rolling walker min (minimum) assist of 1. These orders were reflected in the resident's active care plan as interventions for the focus problem related to activities of daily living. There was no evidence the resident received these services in February or March 2014. The Restorative Care forms used to record the care were blank. During an interview with Employee # 39 (Nurse in charge of Restorative Care) at 8:50 a.m. on 03/25/14, she acknowledged the resident had not received the restorative care services as ordered and planned for in the care plan. She attributed this to low staffing. She acknowledged the resident was able to ambulate with one (1) assistant when he first came to restorative care, but at the present time he traveled the halls in his wheelchair. When asked, she stated she was not sure if the physician was informed of the missed restorative care. d) Resident #1 On 03/25/14 at 2:10 p.m., an interview was conducted with Resident #1 after she requested to talk with someone from the State. She stated, I have only received three (3) days of restorative therapy in the month of March because of the restorative staff being pulled to work the floor and this has been going on since December. Resident #1 further commented, This is hindering me and I have gotten worse by not getting restorative therapy. Review of the resident's medical record, on 03/27/14 at 10:30 a.m., found the resident was re-admitted to the facility on [DATE] after a hospital stay. She had another hospitalized from [DATE] to 11/15/13. Her admission [DIAGNOSES REDACTED]. At 11:05 a.m. on 03/27/14, a review of her quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/20/13, found she had limited functional range of motion (ROM) of the lower extremities on one (1) side. This assessment was prior to her most recent hospitalization in November 2013. Review, on 03/27/14 at 11:15 a.m., of the Medicare 5-day and Medicare 14-day assessments, with ARDs of 11/22/13 and 11/27/13, respectively, found they also indicated she had limitation on one (1) side of her lower extremities. These two (2) assessments were completed after the resident returned from the hospital in November 2013. The quarterly assessment, with an ARD of 01/20/14, indicated the resident had functional limitations of ROM on both sides. This assessment also indicated the resident was totally dependent for locomotion off of the unit, whereas the prior assessments noted she needed extensive assistance. On 12/02/13, the physician ordered restorative therapy for the resident. Orders were written for ambulation and ROM. Review of the Restorative Nursing Record for January, February, and March 2014 found the restorative activities were documented as occurring on only a few occasions each month. Although the extent and actual cause of the resident's declines could not be determined, the resident felt she had declined as a result of not being provided with restorative services. e) Resident #56 During a Stage 1 interview, on 03/17/14 at 2:37 p.m., Employee #93, a licensed practical nurse (LPN), stated Resident #56 had a contracture of her knees. She related the resident had a decline in condition. The resident's minimum data set (MDS), with an assessment reference date (ARD) of 01/09/14, also noted a decline in upper extremity functional range of motion (ROM). Further review of the medical record revealed an order for [REDACTED]. ROM services for March 2014, reviewed on 03/25/14 at 1:49 p.m., found no evidence restorative services were provided. Employee #39 (LPN), restorative nursing supervisor, confirmed the resident had not received ROM due to staffing issues. An interview with Employee #131, rehabilitation program manager, on 03/25/14 at 1:18 p.m., revealed the resident did not receive therapy, as the resident was not appropriate due to her level of dementia. The administrator, interviewed on 03/25/14 at 3:11 p.m., confirmed the facility failed to provide restorative services to prevent further decrease in range of motion. | 2018-01-01 |
| 6572 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 323 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain an environment as free as possible from accident hazards over which the facility had control. Two (2) rooms were found with trip hazards. Resident #12's room had a length of drapery cord lying on the floor. Another room had a crack in the flooring tile resulting in a variance in floor height creating a trip hazard. In addition, an assistance device in a resident bathroom was in poor repair and was not secured properly. The identified issues had a potential to affect more than a limited number of residents. Resident identifier: #12. Facility census: 105. Findings include: a) Resident #12 A review of the medical record revealed Resident #12 was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident was alert and verbal, but very confused and had poor safety awareness. He had experience three (3) falls within the previous two (2) months. During the initial tour observation, at 2:30 p.m. on 03/17/14, the resident's room was entered while he was out of the room attending an activity. The resident's room had sliding glass doors opening to an enclosed grassed area. The drapes on the doors had a long cord which was not anchored. It was lying on the floor in a large loop (approximately 3-4 feet) in an area between the bed and the patio doors. After the environmental tour, at 11:00 a.m. on 03/19/14, the above observation was related to Employee #117, a maintenance worker, who said he would check the drapery cord. During an interview with the Administrator and Employee #116 (Director of Nursing) at 10:45 a.m. on 03/20/14, they acknowledged the resident was more ambulatory when admitted , but both agreed he wandered through the halls propelling himself in his wheelchair. At 11:10 am on 03/24/14, the Administrator stated she had spoken to the maintenance supervisor, who said he installed a new curtain cord guide in the resident's room, and the cord no longer fell on the floor. The administrator did not know how long the old guide had been broken. b) A tour of the 300 hall, at 10:30 a. m. on 03/19/14, found Room #335 had floor tiles with many cracks running the width of the room. One of the cracks in the floor tile was wider and raised on one (1) side and spanned the width of the room. The difference in the floor heights was sufficient to create a trip hazard. This observation was relayed to Employee #117 (Maintenance worker) at 11:00 a.m. on 03/19/14. He acknowledged the floors were in bad shape and he would check room #335. During an interview with the Administrator, at 11:10 a.m. on 03/24/14, she added the facility was in the planning stages of replacing the flooring. She acknowledged the ones posing a hazard should be repaired first. c) Defective assistance device During a room observation, on 03/18/14 at 11:18 a.m., an assistive device for the toilet was observed in disrepair. Bar handles were attached to the back of the commode. The rubber covering over the base of the right leg was half way off, and the bar was tilted to the resident's right when seated. Upon request, Employee #93 a licensed practical nurse (LPN), evaluated the bars. The LPN confirmed the rubber casing on the right leg of the device was not properly secured and the right leg was not stable. Additionally, the bars, attached to the base of the commode were loose, and slid when utilized. Upon inquiry, the LPN said three (3) of the four (4) residents, in the rooms adjacent to the bathroom, utilized the toilet. She also confirmed a potential for an accident was present. | 2018-01-01 |
| 6573 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 332 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, family interview, review of medication information on the Food and Drug Administration website, staff interview, and medical record review, the facility failed to ensure the medication error rate did not exceed 5%. Four (4) errors occurred in twenty-eight (28) opportunities, resulting in a medication error rate of 14.28%. Medications were not administered according to physician's orders [REDACTED]. Resident #94's insulin was ordered to be administered before meals, but was administered after lunch. Resident #54 did not receive nasal sprays as ordered. A nurse crushed a delayed release medication for Resident #30. Facility census: 105. Resident identifiers: Resident #94, #54, and #30. Findings include: a) Resident #94 During a medication administration observation, on 03/19/14 at 12:50 p.m., Resident #94 received a dose of [MEDICATION NAME] three (3) units subcutaneously. This was after the resident had eaten lunch. Employee #125, a licensed practical nurse (LPN) said the resident often took the medication after lunch, according to his preference. Employee #125 further added the resident was on his way to lunch, and she did not want to administer the medication in the hallway. Review of the physician's orders [REDACTED]. During an interview with the resident, on 03/19/14 at 12:50 p.m., a family member stated [MEDICATION NAME] was usually taken before meals. The information about this medication on the Food and Drug Administration (FDA) website includes, WARNINGS [MEDICATION NAME] differs from regular human insulin by a more rapid onset and a shorter duration of activity. Because of the fast onset of action, the injection of [MEDICATION NAME] should immediately be followed by a meal, and DOSAGE AND ADMINISTRATION [MEDICATION NAME] should generally be given immediately before a meal (start of meal within 5 to 10 minutes after injection) because of its fast onset of action. The dosage of [MEDICATION NAME] should be individualized and determined, based on the physician's advice, in accordance with the needs of the patient. Another interview with Resident #94, on 03/20/14 at 8:15 a.m., revealed he usually received [MEDICATION NAME] before lunch. Review of the medical record, on 03/20/14 at 2:00 p.m., revealed no evidence of a physician's orders [REDACTED]. In addition, the care plan did not indicate Resident #94 preferred to take his [MEDICATION NAME] after lunch. b) Resident #54 A medication observation, on 03/19/14 at 11:53 a.m., revealed Resident #54 received saline nasal solution, one (1) spray in each nostril, followed by [MEDICATION NAME], one (1) spray in each nostril. Review of the physician's orders [REDACTED]. An interview with the assistant director of nursing (ADON) on 03/20/14, confirmed the resident received an incorrect dose of medication. c) Resident #30 On 03/19/14 at 11:42 a.m., a medication administration observation revealed Resident #30 received Ferosul 325 mg in a crushed form. Review of the physician's orders [REDACTED]. The do not crush list was reviewed with the assistant director of nursing, on 03/20/14, who confirmed the Ferosul should not have been crushed. | 2018-01-01 |
| 6574 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 353 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to ensure sufficient nursing staff to meet each resident's needs and to assist each resident to attain or maintain the highest practicable physical well-being, as determined by individual assessments and plans of care. The facility failed to provide restorative nursing services, as ordered by the attending physician, for twenty-one (21) of forty-five (45) Stage 2 sample residents. The facility utilized restorative staff to cover the provision of routine care instead of restorative services, due to insufficient staffing. Resident identifiers: #1, #2, #4, #12, #14, #20, #50, #53, #54, #56, #59, #60, #66, #75, #87, #89, #94, #100, #132, #138, and #140. Facility census: 105 Findings included: a) Resident #1 On 03/25/14 at 2:10 p.m., an interview was conducted with Resident #1 after she requested to talk with someone from the state. She stated I have only received three (3) days of restorative therapy in the month of March because of the restorative staff being pulled to work the floor and this has been going on since December. Resident #1 further stated This is hindering me and I have gotten worse by not getting restorative therapy. She also stated the restorative Nursing Aides (NA) are always pulled to the floor to work because of short staffing. At 3:10 p.m. on 03/25/14 an interview was conducted with Employee #32, the Administrator and the survey team. She stated the facility was aware of the staffing problems and had utilized traveling nurses to assist with facility staffing. She said was also aware restorative services staff were utilized frequently to assist with staffing on the units since November 2013. An interview was conducted with Employee #39, a Licensed Practical Nurse (LPN), on 03/26/14 at 10:00 a.m. She introduced herself as the restorative services nurse. During the interview, when asked about Resident #1 receiving restorative services only three (3) days in the month of March, she stated That is true, the restorative staff was pulled to the units to cover for call-offs and when staffing was low. She confirmed this had been a usual occurrence since December 2013. Employee #39 confirmed she and the restorative nurse aides (NA) were not providing residents with restorative services as ordered. b) Residents #1, #2, #4, #12, #14, #20, #50, #53, #54, #56, #59, #60, #66, #75, #87, #89, #94, #100, #132, #138, and #140 A review of the physician orders [REDACTED]. This review found orders for restorative services ranging from range of motion (ROM) to various extremities upper and lower, activities of daily living (ADLs), bilateral lower extremity (BLE) exercises, and ambulation. Review of the restorative nursing records found these residents received restorative services from zero (0) days to only three (3) days during the month of March 2014. Further review of the restorative documentation found restorative services had not been provided with any regularity for December 2013 and January 2014 through the date of the survey in March 2014 c) On 03/27/14 at 8:15 a.m. an interview was conducted with Employee #15, a restorative aide. She stated, I only get to work as a restorative aide a few times a month, otherwise I am pulled to the floor because of call-offs and have to be in staffing. She commented she had noticed a decline in some of the residents because of not receiving restorative therapy. She also stated she had thought of leaving restorative because of never being able to work in that position. d) At 8:35 a.m. on 03/27/14, an interview was conducted with Employee #94, a restorative nurse aide. He commented he was working the floor as a nurse aide more than he worked as a restorative aide. Employee #94 also commented he had noticed a decline in some of the residents because of not receiving restorative therapy. e) Additional findings for individual residents were: 1) Resident #27 This resident was discharged from physical therapy on 02/16/14, with the a goal of Restorative nursing program to be established prior to discharge in order to help pt. (patient) maintain gains achieved during physical therapy services. There was no evidence the resident received restorative nursing care, although the physician also ordered the service. When interviewed at 12:40 p.m. on 03/25/14, Employee #39, the nurse responsible for Restorative Care, confirmed restorative care was not presently being given to Resident #27. She could not state when it had ceased. The forms used by the facility to document restorative care were blank for February and March 2014. Employee #39 attributed the failure to provide restorative nursing services to low staffing, as she and both of the restorative aides were pulled almost daily to provide routine direct care. 2) Resident #14 A review of the medical record of Resident #14 revealed he had been referred to restorative care for an exercise protocol to the right lower extremity when he was discharged from physical therapy on 12/06/13. On 03/06/13, the physician also ordered a restorative dining program due to a significant weight loss and increased need for assistance with eating. Both of those orders remained current and were care planned. When interviewed at 12:40 p.m. on 03/25/14, Employee #39, the nurse responsible for Restorative Care, confirmed restorative care was not presently being given to Resident #27. She could not state when it had ceased. The resident's forms used by the facility to document restorative care were blank for February and March 2014. The nurse stated the resident was taken to restorative dining. She could provide no evaluation of the resident's progress or lack of progress. Employee #39 attributed the failure to low staffing. She said both she and the two (2) restorative aides were pulled almost daily to provide routine direct care. 3) Resident #140 Resident #140 received physical therapy from 01/06/14 - 02/28/14 when services were discontinued because he reached his maximum potential. The resident was referred to Restorative Nursing (RNP) for safety, positioning, and skin integrity. The physician ordered RNP on 01/27/14 for passive range of motion (PROM) and on 02/28/14, added stretching protocol to the order. These orders were received by Employee #15 (restorative care aide) and entered with instructions into the RNP manual. There were no entries indicating the services were provided. When interviewed, at 12:40 p.m. on 03/25/14, Employee #39, (Nurse responsible for Restorative Care) confirmed, except for positioning, restorative care was not presently being given to Resident #140. She could not state if the resident had ever received the services. The forms used by the facility to document restorative care for this resident were blank for February and March 2014. 4) Resident #12 On 06/12/13, the attending physician ordered RNP (Restorative Nursing Program): AROM (active range of motion) to BLE's (bilateral lower extremities) and Ambulation with rolling walker min (minimum) assist of 1. These orders were reflected in the resident's active care plan as interventions for the focus problem related to activities of daily living. There was no evidence the resident received these services in February or March 2014. The Restorative Care forms used to record the care were blank. During an interview with Employee # 39 (Nurse in charge of Restorative Care) at 8:50 a.m. on 03/25/14, she acknowledged the resident had not received the restorative care services as ordered and planned for in the care plan. She attributed this to low staffing. 5) Similar findings were identified for Residents #2, #4, #20, #50, #53, #54, #56, #59, #60, #66, #75, #87, #89, #94, #100, #132, and #138. | 2018-01-01 |
| 6575 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 428 | D | 0 | 1 | BWIF11 | Based on record review and staff interview, the pharmacist failed to identify a medication irregularity during monthly medication reviews for one (1) of six (6) Stage 2 sample residents. A hand written order for insulin did not contain a route of administration. When the order was transcribed into the computer and the medication administration record (MAR), a route was added; however the route was inaccurate. Resident identifier: #66. Facility census: 105. Findings include: a) Resident #66 The medical record was reviewed on 03/19/14 at 11:00 a.m. Resident #66 was a seventy-nine (79) year old male with uncontrolled diabetes who required an Accu-chek instant glucose tests four (4) times a day to monitor his blood glucose level. Review of the resident's medical record found a medication order was handwritten in the chart on 08/06/13. The order was, HumaLOG twelve (12) units before meals. The order did not include a route of administration. The order was put into the computer system as: HumaLOG Solution injection 12 unit intramuscularly before meals related to diabetes. It had a start date of 08/07/13. The medication administration record (MAR) also had, HumaLOG Solution (Insulin Lispro (Human)) Inject 12 unit intramuscularly before meals related to diabetes . It had a start date of 08/07/13. (Note: Humalog is a rapid acting insulin. Insulin injected into a muscle is absorbed more rapidly than when injected into subcutaneous tissue.) The pharmacist's monthly medication regimen review summary indicated Pharmacist #129 reviewed the resident's medications monthly between 09/05/13 and 03/04/14. The pharmacist documented no irregularities and made no recommendations during these six (6)months. The pharmacist did not identify and report the order and MAR indicated the insulin was to be administered intramuscularly instead of subcutaneously. During an interview, on 03/19/14 at 4:30 p.m., registered nurse (RN), Employee #4, reviewed Resident #66's MAR and active orders. The nurse confirmed the insulin order contained an incorrect route, as Humalog insulin was not given intramuscularly. RN #4 agreed the pharmacist should have identified this incorrect order during the monthly review. | 2018-01-01 |
| 6576 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 431 | D | 0 | 1 | BWIF11 | Based on observation, staff interview, and policy review, the facility failed to ensure medications were labeled in accordance with acceptable professional principles. An inhaler was stored with no label containing dispensing orders or to identify the resident to whom it belonged. Facility census: 105. Findings include: a) A220 medication cart An observation of the A220 medication cart on 03/17/14 at 4:00 p.m., found a Ventolin inhaler that was not labeled with a resident's name and was not stored in its original container. There was no label reflecting the dosage and frequency of administration. Upon inquiry, Employee #39, a licensed practical nurse (LPN), said she could not verify to whom it belonged. She said she believed it belonged to Resident #50. The facility's medication storage policy included, Medications designed for multiple administrations (e.g., inhalers, eye drops), the label is affixed in a manner to promote administration to the resident for whom it was prescribed. The LPN confirmed the medication was stored improperly. | 2018-01-01 |
| 6577 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 441 | F | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, information obtained from the Wound, Ostomy Continence Nurses Society, and policy review, the facility failed to develop, implement, and maintain an infection prevention and control program to help prevent the onset and spread of infection. An isolation cart had no wheels and sat directly on the carpet in the hall and eye wash stations were dirty and/or in disrepair. The facility's policy did not identify who could place residents on isolation precautions or who could discontinue the precautions. In addition, the policy did not provide criteria for discontinuing isolation. Surveillance data did not identify when residents were placed on, or taken off of, isolation precautions. Staff did not employ infection control techniques to prevent transmission of microorganisms from resident to resident and/or from the environment to the resident. A glucose meter was not cleaned prior to, or after, use on a resident. Items dropped on the floor were not disposed of properly. A nurse did not wash her hands after removing gloves and accessing the treatment cart. Soiled tape was left on a hand rail. These issues had the potential to affect all residents. Resident identifiers: #56, #12, #112, #97, and #24. Facility census: 105. Findings include: a) Resident #56 Wound dressing changes were observed for Resident #56, on 03/19/14 at 3:30 p.m. Employee #88, a registered nurse (RN), entered the room and washed her hands. Wound care supplies were already on the over-bed table. The RN donned gloves and initiated care of the resident's fourth inner toe. The table was on the opposite side of the bed, away from the nurse's reach. The nurse obtained saline spray and placed it on the resident's mattress without a barrier. After cleansing the wound, she related she needed a measuring grid. The nurse removed her gloves, but did not sanitize her hands before obtaining the grid from the treatment cart, which was located in the hallway. When she reentered the resident's room, the nurse placed the measuring grid on the sink, without a barrier beneath, and washed her hands. Upon completion of hand washing, she donned new gloves, and used the potentially contaminated measuring grid to measure the resident's wound. Upon completion of wound care, Employee #88 returned the unused supplies to the treatment cart. While holding the saline spray in her right hand, she picked up four (4) bags belonging to other residents, brushing them against the bottle of saline spray, before finding the package belonging to Resident #56. This created a potential for transfer of miccroorganisms from Resident #56's bed to the items used for other residents. In addition, while putting away supplies, the RN knocked disposable eating utensils on the floor. She picked them up and placed them on the over-bed table. A second observation was made about fifteen (15) minutes later. The utensils were still on the table. The RN was interviewed and confirmed this provided a mechanism for cross contamination. She said the spoons should have been discarded. Even though the utensils were individually wrapped, this created an opportunity for transfer of potentially pathogenic microorganisms from the floor to the table, and from the table to the resident. Review of the wound dressing policy, on 03/20/14 at 8:40 a.m., revealed the dressing change required aseptic technique. It noted supplies should be placed on a clean barrier. It also noted, if a break in aseptic technique occurred, hands would be washed again. (According to Wound, Ostomy Continence Nurses Society, Aseptic technique is the purposeful prevention of the transfer of organisms from one person to another by keeping the microbe count to an irreducible minimum.) During another interview with Employee #88, on 03/20/14 at 9:00 a.m., the wound dressing change observed on 03/19/14, was reviewed. The RN said she did not know she needed to sanitize her hands after cleansing the wound, and before obtaining supplies from the treatment cart. She also confirmed placement of the measuring grid on the sink, and the saline bottle on the bed, without barriers, provided sources of cross contamination. The infection control supervisor, Employee #4, a registered nurse (RN), was interviewed on 03/20/14 at 9:30 a.m. The observed wound dressing process was reviewed. He confirmed Employee #88 failed to utilize aseptic technique during the dressing change. b) Medication pass . 1) During a medication administration observation, completed on 03/20/14 at 9:27 a.m., Employee #83 (LPN), dropped a disposable spoon on the floor. She picked it up and placed it on the medication cart. Upon inquiry, she confirmed it posed a potential for cross contamination, and should have been discarded. 2) Also, during medication administration observation, Employee #83 removed a glucose meter from the medication cart, completed a finger stick blood sugar, and placed it back on the medication cart without disinfecting the machine. After administering medications to another resident, an inquiry was made as to the protocol for cleaning the glucose meter. The nurse said she would wipe it with an alcohol prep pad. During an interview with Employee #4, the nurse practice educator, on 03/25/14 at 4:45 p.m., he indicated the glucose meters were to be cleansed with a special preparation, and staff were now being educated. He related alcohol was not the appropriate agent for cleaning the glucose meter. He also confirmed the glucose meter should have been cleaned prior to returning it to the medication cart. The glucose meter policy, with a revision date of 10/01/12, indicated the meter was to be disinfected before resident use. During the medication observation, the meter was not disinfected before, or after, the medication administration. c) Hand rail An observation of room [ROOM NUMBER], on 03/17/14 at 3:37 p.m., revealed soiled tape on the right hand rail device (resident's right when seated) attached to the commode. Another observation, on 03/18/14 at 9:20 a.m., again revealed soiled tape on the handrail. A third observation, on 03/24/14, yet again revealed soiled tape on the hand rail. An interview with Employee #76, a licensed practical nurse (LPN), confirmed the tape was soiled, but did not know who was responsible for changing it. He confirmed it was a source for potential cross contamination. d) Resident #12 A review of the medical record revealed Resident #12 was an [AGE] year old male admitted to the facility on [DATE], The resident was alert and verbal, but very confused and had poor safety awareness. Review of the care plan, at 3:00 p.m. on 03/18/14, revealed a Focus problem in the active care plan of gastrointestinal (GI) symptoms requiring Level II precautions (Contact Isolation) which had been initiated on 02/13/14. This resident had been observed in the dining room at 2:30 p.m. on 03/17/14, at an activity. His room had no evidence of isolation. During an interview with Employee #4 (Infection Control Nurse), at 10:50 a.m. on 03/19/14, he was asked if the resident was in isolation. He replied the facility had an outbreak of norovirus which lasted from 02/13/14 until 02/22/14 and all residents exhibiting symptoms were placed in contact isolation. He said Resident #12 was one of those residents, but he was only in isolation for a few days. A review of the Infection Control Surveillance records for February 2014 confirmed the resident had an onset of GI symptoms on 02/13/14, which were resolved on 02/15/14 (this date was provided by Employee #4 because the date on the record was unreadable). Review of physician's orders [REDACTED]. Employee #4 stated according to facility policy, a physician's orders [REDACTED].#4) direction. Employee #116 (Director of Nurses) and Employee #4 were interviewed at 1:00 p.m. on 03/24/14. The DON acknowledged, after reviewing the record, he could not tell when the isolation had been started or discontinued. He confirmed he had reviewed the Infection Control policies and found no requirement for a physician - prescribed plan of care, but neither was there an authorization for nursing to prescribe. e) Resident #112 A review of the medical record revealed Resident #112 was an [AGE] year old male initially admitted to the facility on [DATE] and readmitted on [DATE], after a hospitalization . His [DIAGNOSES REDACTED]. diff), and paralysis agitans. Observation of the resident, during the initial tour on 03/17/14, and throughout the survey (through 03/27/14), revealed he was in contact isolation for [DIAGNOSES REDACTED]. There was no evidence of a physician's orders [REDACTED]. During an interview with Employee #4 (Infection Control Nurse), at 10:50 a.m. on 03/19/14, he was asked when the isolation was initiated. After reviewing the record and his Infection Control Surveillance records, he was unable to provide an exact date. He stated the facility policy did not require a physician's orders [REDACTED]. Further review of the physician's progress notes revealed Resident #112 tested positive for active [DIAGNOSES REDACTED] infection on 02/24/14, and the resident was placed on antibiotics at that time; however, the care plan stating Provide Level II Precautions was not initiated until 03/07/14. Based on the evidence available in the record and the staff interview, the initiation of the isolation into the care plan was not timely. After an interview with the Director of Nurses (DON) and Employee #4, at 1:00 p.m. on 03/24/14, the physician was contacted and an order for [REDACTED]. The DON stated he had not realized the policy did not include who could place a resident in isolation and who could discontinue isolation precautions. During an interview with the Administrator, at 11:00 a.m. on 03/20/14, she stated she was not aware of the lack of a physician's orders [REDACTED]. f) Resident #97 A review of the Infection Control Monthly Line Listing for February 2014 revealed Resident #97 had an onset of gastrointestinal (GI) symptoms on 02/12/14 and the infection was marked resolved on 02/15/14. A culture was collected on 02/15/14, which was reported Positive for Norovirus. During an interview with Employee #4 (Infection Control Nurse), at 10:50 a.m. on 03/19/14, he was asked when the isolation was initiated and discontinued. He referred to the onset and resolved dates and stated those were the dates of isolation. He had no comment regarding the fact the positive culture was collected on the day the isolation was discontinued. The resident's record contained no evidence contact isolation was ordered and/or discontinued by the physician. There also was no entry into the care plan addressing the infection or the isolation interventions. Employee #4 provided a physician's progress note entered into the electronic health record (EHR) on 02/13/14. The note addressed the resident's GI symptoms of vomiting and diarrhea. The note stated assessment/plan acknowledged the implementation of precautions which included Residents will be sequestered to their rooms and will receive all meals and therapy in room until outbreak protocol has been lifted. There was no follow-up progress note, from either the physician or nurses, regarding monitoring the progress of the infection or stating the reason for discontinuing the isolation. At the time of exit, no exact criteria had been provided for discontinuing isolation. g) Resident #24 A Change of Condition form, entered into the electronic health record (EHR) on 02/14/14 by the attending physician, indicated the resident had symptoms of gastroenteritis with frequent vomiting and diarrhea. The entry also noted the facility had met criteria for a GI outbreak. The resident's wife, who occupied the same room, also had the symptoms. The Assessment/Plan included, Residents will be sequestered to their rooms and will receive all meals and therapy in room until outbreak protocol has been lifted. The record contained no evidence contact isolation was ordered and/or discontinued by the physician. There was no entry into the care plan addressing the infection or the isolation interventions. There were no follow-up progress notes, from either the physician or nurses, regarding monitoring the progress of the infection or stating the reason for discontinuing the isolation. During an interview with the Director of Nurses (DON) and Employee #4, at 1:00 p.m. on 03/24/14, Employee #4 referred to the start and resolved dates on the Infection Control Monthly Line Listing and stated the isolation was from 02/14/14 - 02/16/14. The facility's policy did not address who could implement isolation precautions and who could discontinue those precautions. The policy did not identify any criteria for discontinuation of the precautions. At the time of exit, no criteria had been provided for initiating and discontinuing isolation. h) Eye wash stations Observations made during a tour of the facility, at 11:00 a.m. on 03/19/14, revealed the eye wash equipment in the nourishment room on B-330 hall was soiled. The eye wash apparatus on the A-hall was also soiled, with the lens covers hanging and not in place on the lens. This was presented to the Director of Nurses (#116) at 2:45 p.m. on 03/19/14, who stated he would address this immediately. i) Observations on 03/17/14 at 1:00 p.m. and 2:30 p.m., and on 03/18/14 at 8:00 a.m., noted a plastic isolation cart with three (3) drawers containing personal protective equipment (PPE) that included gowns, masks, gloves, and shoe protectors outside of room [ROOM NUMBER]. The isolation cart, without wheels, was sitting directly on the carpeted floor. This inhibited cleaning the carpet beneath and around the cart. On 03/18/14 at 8:45 a.m., an interview was conducted with Employee #4, the infection control nurse. He verified the isolation cart was not on wheels and was sitting directly on the carpeted floor. Employee #4 commented the isolation cart should be on wheels or off the floor in some way for infection control purposes. The isolation cart was immediately replaced, by Employee #4, with an isolation cart with wheels on the bottom to keep it up off the floor. . | 2018-01-01 |
| 6578 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 465 | D | 0 | 1 | BWIF11 | Based on a random observation and staff interview, the facility failed to ensure a sanitary and comfortable environment. Wet linens were not removed from a resident's bed prior to the bed being made. Resident identifier: #68. Facility census: 105. Findings include: a) Resident #68 While conducting an environmental tour of the facility, at 10:30 a.m. on 03/19/14, room 314 was entered. Resident #68 was out of the room at the time. There was a strong odor of urine noted upon entering the room. It was determined the odor was not emanating from the bathroom or the bed/resident near the door. Employee #9 (Patient Care Aide) was directly outside the room and entered, when requested to do so. The aide turned down the covers of the bed near the window (Resident #68's bed), which had already been made. Employee #9 confirmed the bed was wet with urine, but stated she had not been the one who made it. She sought the assistance of Employee #21 (Housekeeper) and they stripped and changed the bed. The incident was reported to the DON during an interview at 2:45 p.m. on 03/19/14. He stated he had already been made aware and was looking into the matter. | 2018-01-01 |
| 6579 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 490 | F | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, and staff interviews, the facility was not administered in a manner which ensured each resident attained or maintained his/her highest practicable well-being. Needed environmental repairs were not addressed and/or prioritized for repair according to potential for harm. Thirty-eight (38) residents were not provided restorative nursing services as ordered and/or care planned due to insufficient staffing. Administration was aware of these issues, but failed to ensure they were promptly addressed. This practice had the potential to affect all residents. Facility census: Findings include: a) Environment Observations, resident interview, and staff interview revealed the facility failed to provide effective housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior. Floor tiles had cracks that were filled with dirt/debris, screens on sliding glass doors were loose, draperies were not hanging properly, and tiles in one room were uneven. 1) A tour of the 300 hall at 10:30 a.m. on 03/19/14, revealed the following observations: -- Rooms #322 and #323 had sliding glass doors opening to an enclosed yard. The screens on the doors were hanging loose from their frames on the outside of the glass. The screens banged on the doors when the wind blew. -- Rooms #310 and #328 had curtains on the sliding doors which were hanging loose in places where they had come loose from the rail. Resident #34 in room [ROOM NUMBER], stated the drapes had been like this a long time. -- Rooms #310, #326, #335, and #328 had floor tiles with many cracks running the width of the room. The cracks were blackened, which revealed an inability to remove all soil from the cracks. In room [ROOM NUMBER] the crack in the floor tile was wider and raised on one side and spanned the width of the room. The difference in the height of the flooring had the potential to cause a person to stumble when crossing the area. During an interview with Employee #117 (Maintenance Supervisor) at 11:00 a.m. on 03/19/14, these issues were discussed. He confirmed the issues existed, and explained the facility had a plan in place to refurbish the resident rooms. He acknowledged that the broken guide which allowed the drapery cord to be on the floor in room [ROOM NUMBER] and the rooms with cracked / missing / uneven floor tiles could cause a hazard and should have been given priority. The refurbishment schedule was confirmed by Employee #32, the administrator, during an interview at 10:00 a.m. on 03/24/14. She supplied a schedule which started on 07/09/2013 and was due to be completed in October 2014. She acknowledged rooms facility-wide should be inspected routinely for need to be prioritized. She also agreed the hanging drapes were a day to day housekeeping issue and should have been addressed. b) Restorative Services Record review, staff interview, and observation revealed the facility failed to ensure twenty-two (22) residents received restorative services as ordered by the physician. Resident identifiers: #27, #14, #140, #87, #12, #56, #1, #2, #4, #20, #50, #53, #54, #59, #60, #66, #75, #89, #94, #100, #132, and #138 1) Resident #27 Medical record review revealed this resident was discharged from physical therapy on 02/16/14. She was supposed to receive a restorative nursing program to help her maintain the gains achieved during physical therapy services. There was no evidence the resident received restorative nursing care, although the physician also ordered the service. The forms used by the facility to document restorative care were blank for February and March 2014. Employee #39, the nurse responsible for restorative care, attributed the failure the resident's restorative care was due to low staffing. Employee #39 indicated she and both of the restorative aides were pulled almost daily to direct care. 2) Resident #14 Review of this resident's medical record revealed he was referred to Restorative Care after discharge from physical therapy on 12/06/13. On 03/06/13, the physician also ordered a Restorative Dining program due to a significant weight loss and increased need for assistance with eating. At the time of the survey, both of those orders remained current and were care planned. When interviewed at 12:40 p.m. on 03/25/14, Employee #39 confirmed restorative care was not presently being given to Resident #27. She could not state when it had ceased. The forms used by the facility to document restorative care were blank for February and March 2014. She stated the resident was taken to restorative dining, but could produce no evaluation of his progress or lack of progress. Employee #39 attributed the failure to low staffing. 3) Resident #140 Observation, at 3:30 p.m., on 03/17/14, revealed this resident's legs were crossed and drawn up to his body. Review of his Physical Therapy evaluation, dated 01/06/14, indicated the resident was assessed with [REDACTED]. This was confirmed by Employee #125 (Rehabilitation Manager) at 9:45 a.m. on 03/20/14. Resident #140 received physical therapy from 01/06/14 - 02/28/14, when services were discontinued because he reached his maximum potential. He was referred to Restorative Nursing (RNP) for safety, positioning, and skin integrity. The physician ordered RNP on 01/27/14 for passive range of motion (PROM) and on 02/28/14, added stretching protocol to the order. These orders were received by Employee #15 (restorative care aide) and entered with instructions into the RNP manual. There were no entries indicating the services were performed. When interviewed at 12:40 p.m. on 03/25/14, Employee #39 confirmed, except for positioning, restorative care was not presently being given to Resident #140. She could not state if the resident had ever received the services. The forms used by the facility to document restorative care were blank for February and March 2014. 4) Resident #87 Resident #87 was observed in bed at 10:30 a.m. on 03/18/14. She was totally dependent for all ADLs and was transferred with a mechanical lift. This was confirmed by Employee #120 at 10:30 a.m. on 03/18/14, who added the resident now only received positioning interventions for comfort. A review of the physician's orders [REDACTED]., Restorative Dining, and Utilize bent built up utensils at all meals. Restorative nursing interventions were ordered by the physician. Documentation revealed they were only performed six (6) times in November 2013 and two (2) times in February 2014. When the medical record was reviewed on 03/24/14, it revealed an order for [REDACTED]. During an interview with the Administrator at 11:00 a.m. on 03/20/14, she stated she was aware the RNP was not being delivered consistently. She had no plan of action for correcting the lack of service. 5) Resident #12 A review of the medical record revealed an order dated 06/12/13, for: RNP (Restorative Nursing Program): AROM (active range of motion) to BLE's (bilateral lower extremities) and Ambulation with rolling walker min (minimum) assist of 1. There was no evidence the resident received these services in February or March 2014. The Restorative Care forms used to record the care were blank. During an interview with Employee # 39, at 8:50 a.m. on 03/25/14, she acknowledged the resident had not received the restorative care services as ordered. She attributed this to low staffing. 6) Resident #1 On 03/25/14 at 2:10 p.m., an interview was conducted with Resident #1. She stated, I have only received three (3) days of restorative therapy in the month of March because of the restorative staff being pulled to work the floor and this has been going on since December. review of the resident's medical record revealed [REDACTED]. Orders were written for ambulation and ROM. Review of the Restorative Nursing Record for January, February, and March 2014 found the restorative activities were documented as occurring on only a few occasions each month. 7) Resident #56 Review of this resident's medical record revealed an order for [REDACTED].>ROM services for March 2014, reviewed on 03/25/14 at 1:49 p.m., found no evidence restorative services were provided. Employee #39 (LPN), restorative nursing supervisor, confirmed the resident had not received ROM due to staffing issues. The administrator, interviewed on 03/25/14 at 3:11 p.m., confirmed the facility failed to provide restorative services for this resident to prevent further decrease in range of motion. 8) Residents #2, #4, #20, #50, #53, #54, #59, #60, #66, #75, #89, #94, #100, #132, and #138 A review of the physician orders [REDACTED]. This review found orders for restorative services ranging from range of motion (ROM) to various extremities upper and lower, activities of daily living (ADLs), bilateral lower extremity (BLE) exercises, and/or ambulation. Review of the restorative nursing records found these residents received restorative services from zero (0) days to only three (3) days during the month of March 2014. Further review of the restorative documentation found restorative services had not been provided these residents, with any regularity, from December 2013 and January 2014 through the date of the survey in March 2014. 9) Review of restorative nursing program (RNP) records, the CMS-802, and the residents' medical records revealed there were active physician's orders [REDACTED]. Review of each of these residents' RNP records revealed none of the thirty-eight (38) residents received the services as ordered in February or March 2014 (as of 03/24/14). A random search revealed the lack of services was also present in November and December 2013. During an interview with Employee #32, the administrator, at 10:00 a.m. on 03/24/14, she acknowledged her awareness of the facility's failure to provide restorative nursing services. She provided information indicating her awareness of the problem as of 11/27/13. Employee #32 acknowledged the restorative nurse and the two (2) restorative aides were pulled frequently to provide routine direct resident care. The Plan in place to free up the RLPN (Restorative LPN) was to give her two (2) days per week starting 03/16/14 in the RNP. There was no mention in the plan for the restorative aides. Employee #32 had no comment when questioned if one (1) nurse could cover 38 residents in two (2) days a week. There was also no evidence the physicians were made aware of the missing services which they continued to order. c) Staffing During an interview with Employee # 39 (Nurse in charge of Restorative Care) at 8:50 a.m. on 03/25/14, she acknowledged the residents had not been provided restorative care services as ordered by their physicians and planned for in the care plans. She attributed this to low staffing and stated both she and the two (2) restorative aides were pulled to provide routine direct care on almost a daily basis. She stated there was also a vacant position for a restorative aide. When asked how long this situation had been present, she first stated, A month or so. When presented with lack of evidence the RNP service was provided as ordered as early as November 2013, Employee #39 agreed it was probably that long. She stated administration was aware of the situation. She was not sure if the physicians were aware. During an interview with Employee #32, the administrator, at 10:00 a.m. on 03/24/14, she acknowledged her awareness of the failure to provide restorative nursing services and agreed the problem was staffing availability. | 2018-01-01 |
| 6580 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 514 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy of the medical record for one (1) of six (6) Stage 2 sampled residents. an order for [REDACTED]. When the order was transcribed into the computer and the medication administration record (MAR), a route was added; however the route was inaccurate. Resident identifier: #66. Facility census: 105. Findings include: a) Resident #66 Review of the resident's medical record on 03/19/14 at 11:00 a.m., found on 08/06/13, a medication order was handwritten in the chart. The order was, HumaLOG twelve (12) units before meals. The order was written into the computer system as: HumaLOG Solution injection 12 unit intramuscularly before meals related to diabetes. with a start date of 08/07/13. The order on the medication administration record (MAR) was written as: Humalog Solution Insulin [MEDICATION NAME] (Human) Inject 12 unit intramuscularly before meals related to diabetes. with a start date of 08/07/13. On 03/19/14 at 4:10 p.m., licensed practical nurse (LPN), LPN #93, reported an order can be written by a nurse, physician, or nurse practitioner. The order was reviewed by the nurse and transcribed to the MAR. The order slip was sent to the medical records department and was transcribed into the computer system within twenty-four (24) hours. During an interview on 03/19/14 at 4:30 p.m., a registered nurse (RN), RN #4, reviewed the original handwritten insulin order dated 08/06/13. The nurse agreed the handwritten order was incomplete. RN #4 reviewed the MAR and active orders and confirmed the insulin order contained an incorrect route. Humalog insulin is not given intramuscularly. ( Humalog is a rapid acting insulin. Insulin injected into a muscle is absorbed more rapidly than when injected into subcutaneous tissue.) At 4:38 p.m., RN #4 presented an in-service training sheet with the topic Order transcription and clarification. Six rights of medication administration: medication, route, time, client, dosage and documentation. He reported he would begin educating the staff immediately. | 2018-01-01 |
| 6581 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 520 | F | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, and staff interviews, the facility's quality assurance (QA) program failed to develop and implement appropriate plans of action to correct quality deficiencies of which it had, or should have had knowledge. Needed environmental repairs were not addressed and/or prioritized for repair according to potential for harm. Thirty-eight (38) residents were not provided restorative nursing services as ordered and/or care planned due to insufficient staffing. The QA committee was aware the services were not being provided. There was no evidence the QA committee took prompt action to address these quality deficiencies. These quality deficiencies had the potential to affect all residents. Facility census: 105 Findings include: a) Environment Observations, resident interview, and staff interview revealed the facility failed to provide effective housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior. Floor tiles had cracks that were filled with dirt/debris, screens on sliding glass doors were loose, draperies were not hanging properly, and tiles in one room were uneven. 1) A tour of the 300 hall at 10:30 a.m. on 03/19/14, revealed the following observations: -- Rooms #322 and #323 had sliding glass doors opening to an enclosed yard. The screens on the doors were hanging loose from their frames on the outside of the glass. The screens banged on the doors when the wind blew. -- Rooms #310 and #328 had curtains on the sliding doors which were hanging loose in places where they had come loose from the rail. Resident #34 in room [ROOM NUMBER], stated the drapes had been like this a long time. -- Rooms #310, #326, #335, and #328 had floor tiles with many cracks running the width of the room. The cracks were blackened, which revealed an inability to remove all soil from the cracks. In room [ROOM NUMBER] the crack in the floor tile was wider and raised on one side and spanned the width of the room. The difference in the height of the flooring had the potential to cause a person to stumble when crossing the area. During an interview with Employee #117 (Maintenance Supervisor) at 11:00 a.m. on 03/19/14, these issues were discussed. He confirmed the issues existed, and explained the facility had a plan in place to refurbish the resident rooms. He acknowledged that the broken guide which allowed the drapery cord to be on the floor in room [ROOM NUMBER] and the rooms with cracked / missing / uneven floor tiles could cause a hazard and should have been given priority. The refurbishment schedule was confirmed by Employee #32 (Administrator and QA Coordinator) during an interview at 10:00 a.m. on 03/24/14. She supplied a schedule, approved by QA, which started on 07/09/2013 and was due to be completed in October 2014. She acknowledged rooms facility-wide should be inspected routinely for need to be prioritized. She also agreed the hanging drapes were a day to day housekeeping issue and should have been addressed. b) Restorative Services Record review, staff interview, and observation revealed the facility failed to ensure twenty-two (22) residents received restorative services as ordered by the physician. Resident identifiers: #27, #14, #140, #87, #12, #56, #1, #2, #4, #20, #50, #53, #54, #59, #60, #66, #75, #89, #94, #100, #132, and #138 1) Resident #27 Medical record review revealed this resident was discharged from physical therapy on 02/16/14. She was supposed to receive a restorative nursing program to help her maintain the gains achieved during physical therapy services. There was no evidence the resident received restorative nursing care, although the physician also ordered the service. The forms used by the facility to document restorative care were blank for February and March 2014. Employee #39, the nurse responsible for restorative care, attributed the failure the resident's restorative care was due to low staffing. Employee #39 indicated she and both of the restorative aides were pulled almost daily to direct care. 2) Resident #14 Review of this resident's medical record revealed he was referred to Restorative Care after discharge from physical therapy on 12/06/13. On 03/06/13, the physician also ordered a Restorative Dining program due to a significant weight loss and increased need for assistance with eating. At the time of the survey, both of those orders remained current and were care planned. When interviewed at 12:40 p.m. on 03/25/14, Employee #39 confirmed restorative care was not presently being given to Resident #27. She could not state when it had ceased. The forms used by the facility to document restorative care were blank for February and March 2014. She stated the resident was taken to restorative dining, but could produce no evaluation of his progress or lack of progress. Employee #39 attributed the failure to low staffing. 3) Resident #140 Observation, at 3:30 p.m., on 03/17/14, revealed this resident's legs were crossed and drawn up to his body. Review of his Physical Therapy evaluation, dated 01/06/14, indicated the resident was assessed with [REDACTED]. This was confirmed by Employee #125 (Rehabilitation Manager) at 9:45 a.m. on 03/20/14. Resident #140 received physical therapy from 01/06/14 - 02/28/14, when services were discontinued because he reached his maximum potential. He was referred to Restorative Nursing (RNP) for safety, positioning, and skin integrity. The physician ordered RNP on 01/27/14 for passive range of motion (PROM) and on 02/28/14, added stretching protocol to the order. These orders were received by Employee #15 (restorative care aide) and entered with instructions into the RNP manual. There were no entries indicating the services were performed. When interviewed at 12:40 p.m. on 03/25/14, Employee #39 confirmed, except for positioning, restorative care was not presently being given to Resident #140. She could not state if the resident had ever received the services. The forms used by the facility to document restorative care were blank for February and March 2014. 4) Resident #87 Resident #87 was observed in bed at 10:30 a.m. on 03/18/14. She was totally dependent for all ADLs and was transferred with a mechanical lift. This was confirmed by Employee #120 at 10:30 a.m. on 03/18/14, who added the resident now only received positioning interventions for comfort. A review of the physician's orders [REDACTED]., Restorative Dining, and Utilize bent built up utensils at all meals. Restorative nursing interventions were ordered by the physician. Documentation revealed they were only performed six (6) times in November 2013 and two (2) times in February 2014. When the medical record was reviewed on 03/24/14, it revealed an order for [REDACTED]. During an interview with the Administrator at 11:00 a.m. on 03/20/14, she stated she was aware the RNP was not being delivered consistently. She had no plan of action for correcting the lack of service. 5) Resident #12 A review of the medical record revealed an order dated 06/12/13, for: RNP (Restorative Nursing Program): AROM (active range of motion) to BLE's (bilateral lower extremities) and Ambulation with rolling walker min (minimum) assist of 1. There was no evidence the resident received these services in February or March 2014. The Restorative Care forms used to record the care were blank. During an interview with Employee # 39, at 8:50 a.m. on 03/25/14, she acknowledged the resident had not received the restorative care services as ordered. She attributed this to low staffing. 6) Resident #1 On 03/25/14 at 2:10 p.m., an interview was conducted with Resident #1. She stated, I have only received three (3) days of restorative therapy in the month of March because of the restorative staff being pulled to work the floor and this has been going on since December. review of the resident's medical record revealed [REDACTED]. Orders were written for ambulation and ROM. Review of the Restorative Nursing Record for January, February, and March 2014 found the restorative activities were documented as occurring on only a few occasions each month. 7) Resident #56 Review of this resident's medical record revealed an order for [REDACTED].>ROM services for March 2014, reviewed on 03/25/14 at 1:49 p.m., found no evidence restorative services were provided. Employee #39 (LPN), restorative nursing supervisor, confirmed the resident had not received ROM due to staffing issues. The administrator, interviewed on 03/25/14 at 3:11 p.m., confirmed the facility failed to provide restorative services for this resident to prevent further decrease in range of motion. 8) Residents #2, #4, #20, #50, #53, #54, #59, #60, #66, #75, #89, #94, #100, #132, and #138 A review of the physician orders [REDACTED]. This review found orders for restorative services ranging from range of motion (ROM) to various extremities upper and lower, activities of daily living (ADLs), bilateral lower extremity (BLE) exercises, and/or ambulation. Review of the restorative nursing records found these residents received restorative services from zero (0) days to only three (3) days during the month of March 2014. Further review of the restorative documentation found restorative services had not been provided these residents, with any regularity, from December 2013 and January 2014 through the date of the survey in March 2014. 9) Review of restorative nursing program (RNP) records, the CMS-802, and the residents' medical records revealed there were active physician's orders [REDACTED]. Review of each of these residents' RNP records revealed none of the thirty-eight (38) residents received the services as ordered in February or March 2014 (as of 03/24/14). A random search revealed the lack of services was also present in November and December 2013. During an interview with Employee #32 (Administrator and QA Coordinator), at 10:00 a.m. on 03/24/14, she acknowledged her awareness of the facility's failure to provide restorative nursing services. She provided information indicating the QA committee was notified of the problem on 11/27/13. Employee #32 acknowledged the restorative nurse and the two (2) restorative aides were pulled frequently to provide routine direct resident care. The Plan in place to free up the RLPN (Restorative LPN) was to give her two (2) days per week starting 03/16/14 in the RNP. There was no mention in the plan for the restorative aides. Employee #32 had no comment when questioned if one (1) nurse could cover 38 residents in two (2) days a week. There was also no evidence the physicians were made aware of the missing services which they continued to order. c) Staffing During an interview with Employee # 39 (Nurse in charge of Restorative Care) at 8:50 a.m. on 03/25/14, she acknowledged the residents had not been provided restorative care services as ordered by their physicians and planned for in the care plans. She attributed this to low staffing and stated both she and the two (2) restorative aides were pulled to provide routine direct care on almost a daily basis. She stated there was also a vacant position for a restorative aide. When asked how long this situation had been present, she first stated, A month or so. When presented with lack of evidence the RNP service was provided as ordered as early as November 2013, Employee #39 agreed it was probably that long. She stated administration was aware of the situation. She was not sure if the physicians were aware. During an interview with Employee #32 (Administrator and QA Coordinator) at 10:00 a.m. on 03/24/14, she acknowledged her awareness of the failure to provide restorative nursing services and agreed the problem was staffing availability. | 2018-01-01 |
| 6583 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 278 | D | 0 | 1 | WK5211 | Based on record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) discharge tracking assessment for one (1) of twenty-six (26) resident admission records reviewed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifier: #119. Facility census: 95. Findings include: a) Resident #119 During Stage 1 admission record review of the QIS, Resident #119's medical record was reviewed on 03/25/14 at 10:00 a.m. The review revealed the resident was discharged to another long term care facility on 02/24/14. Review of the MDS tracking found no evidence a MDS discharge tracking form was completed. Interview with Employee #2, director of nursing, on 03/26/14 at 1:15 p.m., confirmed a MDS tracking form was not completed. | 2018-01-01 |
| 6584 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 279 | D | 0 | 1 | WK5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observations, the facility failed to develop a comprehensive care plan for two (2) of nineteen (19) residents whose care plans were reviewed during Stage 2 of the quality indicator survey. Resident #95 was receiving hospice services. The care plan did not address the coordination of responsibilities between hospice staff and facility staff. Accident hazards were not addressed in the care plan for Residents #67 who spilled hot coffee on himself. Resident Identifiers: #95 and #67. Facility Census: 95 Findings Include: a) Resident #95 Resident #95's medical record was reviewed at 6:22 p.m. on 03/26/14. This review revealed Resident #95 had been receiving hospice services since 02/03/14. Review of the care plan, initiated on 02/03/14, revealed a care plan for hospice which was not individualized for Resident #95. The focus statement was, Palliative Care due to disease process under hospice services. Review of the care plan revealed the following interventions: Hospice CNA to visit and Hospice nurse to visit. The interventions did not specify when the CNA or Nurse would visit, nor did they specify what care each would provide during their visits to the facility. Employee #4, Registered Nurse Assessment Coordinator, RNAC, was interviewed at 10:04 a.m. on 03/27/14. Employee #4 stated she was the RNAC who completed Resident #95's care plan. She reviewed the care plan and stated she was not sure why this care plan was not specific related to the days of the week the Hospice CNA was coming to the building and what the CNA would do for the resident while at the facility. The RNAC also confirmed the specific tasks for the hospice nurse were not included in the care plan. b) Resident #67 Review of the facility's incident / accident reports, at 8:56 a.m. on 03/26/14, found on two (2) occasions the resident spilled hot coffee on himself. On 03/01/13 at 8:11 a.m., the resident spilled a cup of hot coffee on his left side and back area. There was a reddened area measuring seven (7) centimeters (cm) X four (4) cm. The follow-up documentation was for staff to cool Resident #67's coffee prior to serving the resident. Another incident, dated 09/13/14 at 12:48 p.m., revealed Resident #67 spilled hot coffee, causing a reddened area to the right anterior forearm near the elbow. During the noon meal on 03/26/14, Resident #67 was provided a cup of hot coffee. Staff did not cool the resident's coffee prior to serving it to him. At 10:45 a.m. on 03/26/14, the care plan of Resident #67 was reviewed. The care plan failed to address safety issues or any plan to protect the resident [MEDICAL CONDITION] to hot liquids. The care plan did not address the previous two (2)burns, nor did it address the potential for additional burns. At 1:45 p.m. on 03/26/14, the administrator and the director of nursing (DON) were interviewed and were asked what plans had been put into place to prevent Resident #67 from receiving further injury from spillage of hot coffee. The DON and the administrator were unable to provide evidence the care plan provided any interventions to ensure Resident #67 did not sustain further injury from hot coffee. | 2018-01-01 |
| 6585 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 280 | D | 0 | 1 | WK5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plans for three (3) of nineteen (19) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The care plans / interventions were not revised after Resident #26 no longer required bed rest. The care plan was not updated to reflect the addition of a lower extremity orthotic device ordered for Resident #117. The care plan for Resident #20 was not revised after a dental consult. Resident identifiers: #26, #117 and #20. Facility census: 95. Findings include: a) Resident #26 Review of the medical record on 03/25/14 found the resident had a history of [REDACTED]. The care plan contained a focus problem, updated on 12/02/13: (name of resident) experienced an actual fall and has a history of falls while out with family and in her room, she is at risk for further falls. On 01/07/14, an intervention was initiated for prevention of falls. It included Bedrest for 2 to 3 days. The resident's nursing assistant, Employee #102, was interviewed at 4:00 p.m. on 03/25/14. Employee #102 stated the resident was no longer on bed rest. Employee #4, the registered nurse assessment coordinator (RNAC), was interviewed on 03/25/14 at 4:11 p.m. Employee #4 stated the bed rest was initiated after a fall which occurred on 01/05/14. She verified the resident was no longer on bed rest, and the intervention should have been removed from the care plan. b) Resident #117 Medical record review on 03/26/14 found the resident currently had a Stage III pressure area to the left outer ankle, and an unstageable pressure area to the left lateral foot. The physician's orders [REDACTED]. Review of the current care plan, revised on 03/26/14, found a focus problem: (Name of resident) has a pressure ulcer upon return from hospital to left outer ankle. Currently has excoriation to buttocks. Pressure ulcer to left lateral foot. The 03/26/14 care plan did not include the orthotic device which was ordered on [DATE]. Employee #3, the registered nurse assessment coordinator (RNAC), was interviewed at 7:00 p.m. on 03/26/14. Employee #3 confirmed the care plan was not revised to include the orthotic device, which was ordered on [DATE]. c) Resident 20 Resident #20's medical record was reviewed at 9:15 a.m. on 03/27/14. This review revealed Resident #20 was seen by the dentist on 02/06/13. The review of the consult revealed Resident #20 was not cooperative with the dental exam. The consult indicated unless the resident began to experience pain, she would not need to have a follow up appointment. Resident #20's care plan pertaining to dental status revealed the resident's care plan contained an intervention, dated 02/04/13: Coordinate arrangements for dental care, transportation as needed/as ordered. Appt (appointment) (Name of Dentist) on 02/06/13. The resident's care plan was not updated, after the resident was seen by the dentist on 02/06/14, to reflect the need for a follow-up appointment only if she began to experience pain. Employee #3, Registered Nurse Assessment Coordinator (RNAC), was interviewed at 9:42 a.m. on 03/27/14. She confirmed the care plan was not clear in regards to Resident #20's dental appointments. | 2018-01-01 |
| 6586 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 323 | D | 0 | 1 | WK5211 | Based on observation, staff interview, and record review, the facility failed to ensure an environment which was as free as possible from accident hazards over which the facility had control. The facility failed to implement interventions, including adequate supervision, which was consistent with the needs for one (1) of three (3) residents reviewed who had accidents with spilled hot liquids. Resident identifier #67. Facility census: 95. Findings include: a) Resident #67 Review of incident/accident reports, at 8:56 a.m. on 03/26/14, revealed the resident spilled hot coffee on himself on 03/01/13. A reddened area, measuring seven (7) centimeters (cm) X four (4) cm., was noted on his left side and back area. The follow-up documentation was for staff to cool Resident #67's coffee prior to service. Another incident, dated 09/13/13 at 12:48 p.m., revealed Resident #67 again spilled hot coffee on himself. This time he sustained a reddened area to his right anterior forearm near the elbow. Review of the facility follow-up notes, dated 09/14/13 to 09/16/13, under the section titled, interventions put in place to prevent reoccurrence, the only intervention was to monitor the area. The interventions did not describe how the facility would prevent the same accident in the future. At 9:50 a.m. on 03/26/14, Employee #9, the dietary manager (DM), was interviewed. The DM stated kitchen staff provided a pitcher of ice cubes with the coffee, and staff were instructed to cool the coffee of residents at the time of service. At 10:45 a.m. on 03/26/14, the care plan for Resident #67 was reviewed. The care plan did not address safety issues or a plan to protect the resident from burns related to hot coffee. The previous two (2) burns, and the potential for burns related to hot coffee, were not addressed in the care plan. Observation of the noon meal, which began at 12:16 p.m. on 3/26/14, found Resident #67 was provided with a cup of coffee. Although there was an intervention to cool the resident's coffee after the incident on 03/01/13, the coffee was not cooled by the staff at this meal. At 1:45 p.m. on 03/26/14, the administrator and the director of nursing (DON) were interviewed. They were asked what plans were put into place to prevent Resident #67 from being burned from spillage of hot coffee. The DON pointed out the signs in the pantry areas of the facility which instructed staff to, please cool coffee with ice cubes. She provided documentation of in-services related to serving hot coffee to residents; however, these in-services were dated 10/28/12, 11/10/12 and 11/26/12. The DON stated Resident #67 was offered a special cup to use for his hot coffee, but refused the cup. She stated he also refused to have his coffee cooled. The DON was unable to provide verification these interventions were attempted, evaluated, and/or reassessed to establish effective safety measures for the resident. She agreed the care plan did not contain interventions to prevent potential injury from hot coffee. | 2018-01-01 |
| 6587 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 329 | D | 0 | 1 | WK5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's medication regimen was free from unnecessary medications for three (3) of five (5) residents reviewed for unnecessary medication during Stage 2 of the Quality Indicator Survey. The facility failed to monitor an apical pulse prior to the administration of [MEDICATION NAME] (a heart medication) for Resident #13. For Resident #80, the facility failed to attempt a gradual dose reduction for the use [MEDICATION NAME](a hypnotic). Resident #45 was receiving [MEDICATION NAME] (a [MEDICAL CONDITION] medication) without monitoring of identified behaviors. Resident identifiers: #13, #80 and #45. Facility census: 95. Findings include: a) Resident #13 The medical record for Resident #13 was reviewed on 03/26/14 at 2:15 p.m. Resident #13's [DIAGNOSES REDACTED]. The March 2014 physician's orders [REDACTED]. The Nursing 2014 Drug Handbook, the medication reference book used by the facility's licensed nurses, was reviewed on 03/26/14. The directions for oral administration for [MEDICATION NAME] (on page 442) instructed an apical pulse should be taken for one (1) minute before administering [MEDICATION NAME]. This information was to be recorded, and the prescriber notified of significant changes in the pulse. Review of the Medication Administration Record [REDACTED]. Interview with Employee #2, the director of nursing (DON), on 03/26/14 at 4:00 p.m., confirmed an apical pulse was to be obtained prior to the administration of [MEDICATION NAME]. She further confirmed Resident #13 received the medication without monitoring of the apical pulse. On 03/26/14 at 5:15 p.m., a telephone interview was conducted with Employee #142, the consultant pharmacist. He confirmed the medication, [MEDICATION NAME], required an apical pulse to be obtained prior to the administration of the medication. b) Resident #80.Resident #80's medical record was reviewed on 03/26/14 at 1:00 p.m. The resident had been receiving the [MEDICATION NAME] mg daily for eight (8) months, since 07/25/13, for [MEDICAL CONDITION], without an attempt at a gradual dose reduction (GDR). According to the guidance to surveyors at 483.25 (l), For as long as a resident remains on a sedative/hypnotic that is used routinely during the previous quarter, the facility should attempt to taper the medication at least quarterly. Before one can conclude that tapering is clinically contraindicated for the remainder of that year, tapering must have been attempted during the previous three quarters.The consultant pharmacist reviewed the resident's medication regimen on 02/03/14. He recommended [MEDICATION NAME] mg be slowly tapered and discontinued. He stated, It is recommended to limit the use of sedative-hypnotics to short term use (10-14 days) as long term use increases the risk for adverse events and dependence which often outweighs the benefit of continued therapy.Employee #2, DON, was interviewed on 03/26/14 at 10:00 a.m. She reviewed the medical record and confirmed there had been no GDR for the resident's Ambien. c) Resident #45 The resident's medical record was reviewed on 03/25/14 at 3:38 p.m., This review revealed Resident #45 was receiving [MEDICATION NAME] one (1) mg twice a day since 02/04/14. Resident #45's care plan contained the following focus statement: (Resident Name) receives antipsychotic ([MEDICATION NAME]) due to dementia with inappropriate sexual remarks. Review of Resident #45's monthly behavioral flow sheets for February and March 2014 revealed the facility was not monitoring inappropriate sexual remarks. An interview with the DON was conducted at 5:00 p.m. on 03/26/14. She confirmed a discussion had just been held with her staff regarding the resident's continued inappropriate sexual remarks. The DON said the facility used behavioral flow sheets to track daily behaviors when residents were taking antipsychotic medications. The DON said staff should be monitoring Resident #45 for inappropriate sexual comments. She said this should be on the behavioral monitoring forms for the resident. The DON reviewed the monthly behavioral flow sheets for the months of February and March 2014. She stated the behavior of inappropriate sexual comments was not on the form; therefore, it was not being monitored. | 2018-01-01 |
| 6588 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 364 | E | 0 | 1 | WK5211 | Based on resident interview, staff interview, observation, and food temperature assessment, the facility failed to ensure hot food items were served at the temperature satisfactory to the residents. Four (4) of twelve (12) residents interviewed during Stage 1 of the Quality Indicator Survey (QIS) voiced complaints about food temperatures. Resident identifiers: #12, #92, #37, and #52. Facility census: 95. Findings include: a) Resident interviews During Stage 1 of the QIS, the following interviewable residents were asked, Is the food served at the proper temperature? 1. Resident #12 Resident #12 was interviewed at 4:37 p.m. on 03/24/14. The resident stated the food was cold, and he could not eat it. 2. Resident #92 Resident #92 was interviewed at 1:51 p.m. on 03/25/14. The resident stated sometimes the food was cold. 3. Resident #37 The resident was interviewed at 11:08 a.m. on 03/25/14. She complained of receiving cold food. 4. Resident #52 The resident was interviewed at 4:33 on 03/24/14. She stated the breakfast meal was usually cold, especially the eggs and coffee. b) On 03/06/14 at 8:15 a.m., food temperatures were obtained at the time of service on B-hall by Employee #9, the dietary manager. According to professional standards of practice, hot foods should be served at or above 120 degrees Fahrenheit. The scrambled eggs were 103 degrees Fahrenheit and the bacon was 89 degrees Fahrenheit. c) On 03/06/14 at 8:20 a.m., observation of the food temperature log with Employee #91, the cook and Employee #9, the dietary manager, found the temperature of the eggs was recorded as 182.2 degrees Fahrenheit before leaving the kitchen. The temperature of the bacon was not recorded on the food temperature log before leaving the kitchen. The dietary manager confirmed the temperature of the eggs and bacon at the time of service was not acceptable. | 2018-01-01 |
| 6589 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 371 | F | 0 | 1 | WK5211 | Based on observation and staff interview, the facility failed to ensure foods were stored in a manner which maintained sanitary conditions. Food items found in the reach-in refrigerator were without labels and/or dates. Food items were not dated to indicate when they were opened or prepared and/or when they should be discarded. This had the potential to affect all residents who received nourishment from the dietary department. Facility census: 95. Findings include: a) During the initial tour of the kitchen with Employee #93, the dietary services assistant, at 2:45 p.m. on 3/24/14 the following unlabeled and/or undated food items were found in the reach-in refrigerator: -- a Styrofoam container of ribs -- a stick of butter in a storage bag -- several slices of cheese in a storage bag -- a serving tray containing various food items in bowls -- several glasses of beverages and two (2) sandwiches. Employee #93 stated she would discard the food items. The above observations were discussed with Employee #9, the dietary manager, at 10:00 a.m. on 03/25/14. | 2018-01-01 |
| 6590 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 428 | D | 0 | 1 | WK5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the identification of medication irregularities and/or act on identified irregularities for two (2) of six (6) residents reviewed. Resident #80 had a physician's orders [REDACTED]. The pharmacist failed to identify the facility was not obtaining an apical pulse prior to the administration of the medication. In addition, the pharmacist recommended Resident #13 have a gradual dose reduction of Ambien. This was not acted upon by the physician. Resident identifier: #13 and 80. Facility census: 95.Findings include: a) Resident #13A medical record review was completed at 2:30 p.m. on 03/26/14. This review revealed the resident had a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. This review revealed the resident had not had an apical pulse recorded during this time frame. The medical record revealed a chronological record of medication regimen reviews for Resident #13. The pharmacist reviewed the resident's drug regimen on 01/07/14, 02/03/14 and 03/06/14. The pharmacist failed to identify an apical pulse was not being obtained prior to the administration of Digoxin. Employee #2, Director of Nursing (DON), was interviewed at 3:00 p.m. on 03/26/14. She confirmed the pharmacist had failed to identify the need for an apical pulse prior to the administration of Digoxin. On 03/26/14 at 5:15 p.m. an interview by phone was conducted with Employee #142, consultant pharmacist. He confirmed the medication, Digoxin, required an apical pulse to be obtained prior to the administration of the medication. He further confirmed he failed to identify the need for an apical pulse prior to the administration of Digoxin.b) Resident #80Medical record review, on 03/26/14 at 10:30 a.m., revealed on 02/03/14, the pharmacist had made a recommendation for a gradual dose reduction (GDR) for Ambien. The physician had declined the recommendation, noting doing well on it, but did not elaborate with resident specific information as requested by the recommendation. Employee #2, DON, was interviewed on 03/26/14 at 10:00 a.m. She reviewed the medical record, including the physician's progress notes. The DON confirmed the physician had not provided resident specific information related to the refusal for a GDR of Resident #80's Ambien. According to the guidance to surveyors at 483.25 (l), For as long as a resident remains on a sedative/hypnotic that is used routinely during the previous quarter, the facility should attempt to taper the medication at least quarterly. Before one can conclude that tapering is clinically contraindicated for the remainder of that year, tapering must have been attempted during the previous three quarters.The consultant pharmacist reviewed the resident's medication regimen on 02/03/14. He recommended the Ambien 5 mg be slowly tapered and discontinued. He stated, It is recommended to limit the use of sedative-hypnotics to short term use (10-14 days) as long term use increases the risk for adverse events and dependence which often outweighs the benefit of continued therapy.The pharmacist further stated if the therapy was continued, it was recommended the prescriber document an assessment of risks verses benefits, indicating the medication continued to be a valid therapeutic intervention for the resident. The pharmacist also suggested the facility's interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences. There was no evidence the physician acted upon the recommendation by providing this documentation. | 2018-01-01 |
| 6591 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 441 | E | 0 | 1 | WK5211 | Based on observations and staff interview, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of disease and infection. The staff placed a contaminated tray on a meal cart containing a clean tray. This had the potential to affect more than a isolated number of residents. Facility census: 95. Findings include: a) Observation of the breakfast meal cart on B-hall at 8:15 a.m. on 03/26/14 with the dietary manager (DM), Employee #9, found the contaminated meal tray of Resident #116 was placed in the cart containing a clean meal tray. Several nursing assistants were present in the hallway when the observation was made with Employee #9. At the time of discovery, only one (1) tray, belonging to Resident #81, remained on the meal cart. When questioned, facility staff members were unable to state who placed the meal tray in the meal cart, or how long the meal tray had been on the cart. For this reason, it could not be determined if other residents' meal trays were contaminated by Resident #116's meal tray. The DM confirmed this practice was not acceptable and he ordered another tray for Resident #81. | 2018-01-01 |
| 6592 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 514 | D | 0 | 1 | WK5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medical record for one (1) of six (6) residents reviewed during Stage 2 of the Quality Indicator Survey was accurate and complete. A physician ordered laboratory service was not provided. The medical record contained no documentation regarding why the laboratory service was not obtained for the resident. Resident identifier: #94. Facility census: 95. Findings include: a) Resident #94 Medical record review, on 03/26/14, found a nurse's note, dated 01/14/14, Daughter visiting and concerned that patient is weak and not eating well. Patient had poor po ( by mouth) intake for breakfast and lunch. Skin warm and dry. Skin turgor good. No signs of dehydration at this time. Per (Name of physician) ordered Align one daily and UA (urinalysis) and C & S (culture and sensitivity) if indicated. Further review of the medical record found no evidence the urinalysis was obtained as ordered. The medical record had no physician's order which rescinded the UA and C & S orders. The director of nursing (DON) was interviewed at 5:52 p.m. on 03/26/14. She was asked if the urinalysis was obtained. During an interview at 6:00 p.m. on 03/26/14, the DON stated the physician came in the following day (01/16/14) to visit the resident before the urinalysis was obtained. She said the physician decided the urinalysis was not needed because the resident was on [MEDICATION NAME] for [MEDICAL CONDITIONS]. The DON was unable to provide documentation regarding this statement, or other verification the order was discontinued. On 03/26/14, after intervention during the survey, the physician entered a late entry, note for 01/15/14. The noted stated: . Advised staff urinalysis would likely not be necessary to obtain, as her symptoms were related to recurrent [MEDICAL CONDITION] infection of the stool | 2018-01-01 |