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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6226 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 272 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of two (2) comprehensive minimum data sets (MDSs) for two (2) of six (6) residents whose MDSs were reviewed. Resident #920's Annual MDS did not accurately reflect the number of days the resident received anticoagulation medications. Resident #923's admission MDS inaccurately indicated the resident had contractures. Resident Identifiers: #920 and #923. Facility Census: 38. Findings Include: a) Resident #920 A review of Resident #920's medical record at 10:28 a.m. on 04/22/15 found an Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/15. Review of the MDS found Section N0410 E. Anticoagulant coded with a seven (7) to indicate Resident #920 received anticoagulation medication seven (7) of the seven (7) days in the look back period. Resident #920's Medication Administration Record [REDACTED]. The medication was held on the other two (2) days at the direction of the attending physician. An interview with the Director of Nursing (DON) at 1:00 p.m. on 04/22/15, confirmed Resident #920 only received her [MEDICATION NAME] (an anticoagulant medication) on five (5) of the seven (7) days during the look back period. When asked if the MDS with the ARD of 01/29/15 Section N0410 E. Anticoagulant was coded accurately she replied, No it should have been a five (5) and I put seven (7). b) Resident #923 Review of Resident #923's medical record at 10:00 a.m. on 04/23/15, found an Admission MDS with an ARD of 10/23/15. Review of this MDS found Section S3100 Contractures - A. Hand, coded with a three (3) indicating Resident #923 had contractures of both hands. Additionally, Section S3100 Contractures -F. Ankle, indicated Resident #923 had a contracture of her right ankle. Further review of the medical record found no indication Resident #923 had contractures of her hands or right ankle. An interview with the Director of Nursing (DON) at 2:48 p.m. on 04/23/15, confirmed Resident #923 did not have contractures. The DON indicated the [DIAGNOSES REDACTED].#923 had not been diagnosed as having a contracture. She confirmed the annual MDS, with an ARD of 10/23/14, was inaccurately completed in regards to contractures and needed corrected. | 2018-04-01 |
| 6227 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 274 | D | 1 | 0 | 0UGG11 | Based on record review, staff interview, review of the guidance for this regulation, review of Chapter 2 of the Resident Assessment Instrument Manual, and family interview, the facility failed to complete a significant change in status minimum data set (MDS) assessment within 14 days after the facility determined, or should have determined, one (1) of six (6) sampled residents experienced a significant change in status. Resident #931 had declines in bed mobility, transfers, ambulation, dressing, eating, toilet use, personal hygiene, bladder and bowel continence, and weight. Resident identifier: #931. Facility census: 38. Findings include: a) Resident #931 On 04/20/15 at 1:10 p.m., during an interview with the Medical Power of Attorney (MPOA) for Resident #931, the MPOA voiced concern over the resident's decline in health. The MPOA said the resident's appetite had decreased over the past few months and she was losing weight, as well as declining in her functional abilities. She said the resident used to walk in the facility using a walker, but had not walked in a few months. Record review, on 04/20/14 at 1:40 p.m. found the following: 1. Quarterly MDS with an assessment reference date (ARD) of 12/11/14 Coding for G0110 indicated -- Bed mobility - coded 3/2 - indicating the resident required extensive assistance of one (1) staff member for the seven (7) day look back period. -- Transfers, Walk in room, Walk in corridor, Dressing, Toilet Use, and Personal Hygiene - coded 2/2 - indicating the resident required the limited assistance of one (1) staff member for the activity during the seven (7) day look back period. -- Eating - coded 0/1 - indicating the resident was independent and required only set-up assistance from staff during the seven (7) day look back period. Items H0300 and H0400 - indicated the resident was always continent of urine and bowel during the seven (7) day look back period. Item K0200 identified the resident's weight was 129 pounds Item K0300 indicated the resident had not had a weight loss of 5% or more in the last month or loss of 10% or more in the last six (6) months. 2. Annual MDS with an ARD of 03/05/15 Review of the next MDS, an annual assessment with an ARD of 03/05/15, found: Item G0110: -- Bed mobility, Transfers, Dressing, Eating, Toilet Use, and Personal Hygiene - coded 4/2 - indicating the resident required full staff performance of one (1) staff member for these activities during the seven (7) day look back period. -- Walk in room, Walk in the corridor - coded 8/8 - indicating the activity did not occur during the seven (7) day look back period. Items H0300 and H0400 indicated the resident was always incontinent of urine and bowel during the seven (7) day look back period. Item K0200 identified the resident weighed 113 pounds (the prior assessment listed her weight 129 pounds - this would represent a weight loss of 12.4% in 3 months). Item K0300 indicated the resident did not have a weight loss of 5% or more in the last month or loss of 10% or more in the last six (6) months. b) On 04/21/15 at 11:45 a.m., upon inquiry as to the resident's functional decline, Licensed Practical Nurse #19 said the resident had been on antibiotics recently. The nurse said the resident had not eaten well lately, and had a general overall decline in health. At 4:00 p.m. on 04/21/15, the Director of Nursing (DON), when made aware of the findings regarding the resident's decline in functional ability, weight loss, and loss of bowel and bladder continence, said when all the areas of decline were put together, it did seem like a significant change had occurred. She said the facility completed significant change MDS assessments when an improvement was not foreseen within two (2) weeks. The DON agreed the resident's functional ability had not improved in longer than two (2) weeks. The DON confirmed a significant change MDS assessment should have been completed to assess the resident's decline in condition. The guidance for significant change includes, The following are the criteria for significant changes: A significant change reassessment is generally indicated when a resident elects, and revokes, the hospice benefit, and if decline or improvement is consistently noted in 2 or more areas of decline or 2 or more areas of improvement: Decline: - Any decline in activities of daily living (ADL) assistance where a resident is newly coded as 3, 4 or 8 Extensive Assistance, Total Dependence, activity did not occur (note that even if coding in both columns 1 and 2 of an ADL category changes, this is considered 1 ADL change); . - Resident's incontinence pattern changes from 0 or 1 to 2 or 3, or placement of an indwelling catheter; - Emergence of an unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); - Overall deterioration of resident's condition; resident receives more support (e.g., in ADLs or decision making). The Resident Assessment Instrument Version 3.0 Manual includes on page 2-20, A significant change is a decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting (for declines only); 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. | 2018-04-01 |
| 6228 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 278 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the minimum data set (MDS)assessments, for one (1) of six (6) residents whose MDSs were reviewed, was not accurate. Resident #923 had two (2) quarterly MDSs which did not accurately reflect contractures. Resident Identifier: #923. Facility Census: 38. Findings Include: a) Resident #923 1. Review of Resident #923's medical record, at 10:00 a.m. on 04/23/15, found a quarterly MDS, with an Assessment Reference Date (ARD) of 01/08/15. The assessor coded this MDS, Item S3100 - Contractures to indicate the resident had contractures of both hands. Additionally, the assessment identified the resident had a contracture of her right ankle. Further review of the medical record found no indication Resident #923 had contractures of her hands or right ankle. 2. Review of Resident #923's medical record at 10:00 a.m. on 04/23/15 found a quarterly MDS with an ARD of 03/26/15. This assessment also indicated the resident had contractures of both hands and her right ankle. Further review of the medical record found no indication Resident #923 had contractures of her hands or right ankle. 3. An interview with the Director of Nursing (DON) at 2:48 p.m. on 04/23/15, confirmed Resident #923 did not have contractures. The DON indicated the [DIAGNOSES REDACTED].#923 had not been diagnosed as having a contracture. She confirmed the quarterly MDSs with ARDs of 01/08/15 and 03/26/15 were inaccurate related to contractures and needed corrected. | 2018-04-01 |
| 6229 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 279 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop an interdisciplinary care plan describing the services needed to meet the needs of one (1) of six (6) residents reviewed during the complaint investigation. The facility failed to develop a care plan addressing Resident #931's urinary tract infection [MEDICAL CONDITION], which was treated in February 2015. Resident identifier: #931. Facility census: 38 Findings include: a) Resident #931 A review of the resident's medical records, on 04/21/15, identified Resident #931 received a course of antibiotics for a UTI. A urinalysis (UA) and culture and sensitivity (C&S) were ordered on [DATE], due to a functional decline. The results of the UA identified the microorganism Proteus Mirabilis, with a colony count greater than 100,000. On 02/02/15, after receiving the C&S results, the physician ordered [MEDICATION NAME] (an antibiotic) 500 milligrams (mg) to be given by mouth three (3) times a day for seven (7) days. At 11:40 a.m. on 04/21/15, a review of the care plan for Resident #913 found no evidence in the current care plan, or resolved episodic care plans, which indicated the resident had a UTI and received an antibiotic, or had a history of [REDACTED]. On 04/23/15 at 11:00 a.m., when asked to provide any episodic care plans regarding the UTI in February 2015, which might have been thinned from the resident's record, the Director of Nursing (DON) said she would check. At 11:30 a.m. on 04/23/15, the DON verified there was no care plan for the UTI treated in February 2015. She confirmed an episodic plan should have been established. | 2018-04-01 |
| 6230 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 282 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, record review, and staff interview, the facility failed to ensure implementation of the care plans for three (3) of six (6) residents whose care plans were reviewed. Resident #894's care plan related to her risk of elopement was not implemented. Resident #920's care plan related to her risk of falls was not implemented. In addition, Resident #913 had a care plan for restorative services. Staff were unable to describe the restorative services they provided the resident. Resident Identifiers: #894, #920, and #913. Facility Census: 38 Findings Include: a) Resident #894 Review of Resident #894's care plan, at 2:15 p.m. on 04/20/15, found a problem of, At risk for elopement. The goal was, Will have 0 (zero) further elopement attempts qd (daily). The interventions to achieve this goal were (typed as written): Keep behavior log QS (every shift). Make sure she has an ID (identification) bracelet on AAT (at all times). Orange runner on door. Info (information) in Kardex so staff are aware. Frequent monitoring. Observations of Resident #894, at 3:15 p.m. on 04/20/15, found she did not have an orange runner on her door and she was not wearing an identification bracelet. A review of Resident #894's Kardex found no mention of her risk for elopement, nor her interventions to prevent elopement. (The Kardex was the method used by the facility to communicate care plan interventions to direct care staff.) Additional observations of Resident #894 with the Director of Nursing (DON), at 3:37 p.m. on 04/20/15, confirmed Resident #894 did not have an orange runner on her door, nor was she wearing an identification bracelet. The DON reviewed the resident's Kardex upon request. After reviewing the Kardex, she confirmed the resident's risk for elopement and the interventions to prevent elopement were not documented on the Kardex. She also confirmed facility staff did not implement Resident #894's care plan interventions related to elopement. b) Resident #920 Review of Resident #920's care plan, at 10:28 a.m. on 04/22/15, found a care plan problem of, Fall Risk. The goal associated with this problem was, Will have 0 (zero) falls QD (daily). The interventions included, Assist X (times) 2 (two) with (indicated by symbol of with) showers. The last revision of the care plan was dated 01/29/15, with a target date of 04/23/15. Review of the resident's activities of daily living (ADL) flow sheets, for 01/29/15 through 04/21/15, found Resident #920 received showers on 02/04/15, 02/08/15, 02/15/15, 02/19/15, 02/22/15, 02/26/15, 03/01/15, 03/12/15, 03/15/15, 03/29/15, 04/02/150, 4/05/15, 04/09/15, 04/16/15, and 04/19/15. On each date, the ADL flow sheet indicated Resident #920 was totally dependent for showering with a one (1) person physical assist. At 9:30 a.m. on 04/22/15, the DON reviewed the ADL flow sheets and stated they indicated Resident #920 only received the assistance of one (1) staff member with showering. She reviewed Resident #920's fall risk care plan and confirmed, based on the facility documentation, the resident's care plan related to for fall risk was not implemented. c) Resident #913 A review of the physician's orders [REDACTED]. 1. In January, February, March and April 2015 the resident had physician orders [REDACTED]. 2. In February of 2015, the resident had a physician's orders [REDACTED]. The restorative ambulation was marked as completed until the order was discontinued on 02/24/15. 3. Beginning on 02/25/15, the resident received restorative transfers, indicating the resident would transfer from the bed to a wheelchair with the assistance of one (1) staff member. The resident would bear weight and pivot. Both the restorative AROM and transfers were marked as completed for the remainder of February, March, and to the time of the review on 04/21/15. Review of the resident's care plan, on 04/21/15 at 11:40 a.m., found the plan identified the restorative program as an intervention for the resident's ADLs. These restorative services were also identified on the Kardex (the care plan for use by nursing assistants). At 3:00 p.m. on 04/21/15, when asked to describe restorative services provided for Resident #913, Nurse Aide (NA) #1, the NA in charge of the restorative program, said the resident received AROM of her upper and lower extremities twice a day. She said the resident also received restorative ambulation. This was provided by the resident walking from her room to the dining room with staff assistance and the aide of a walker. When asked when she last provided these services for the resident, NA #1 said, It was one day last week, I can't remember the exact day, it was Wednesday or Thursday. On 04/21/15 at 4:00 p.m., the DON was made aware of NA #1's description of the restorative services provided for Resident #931. The DON verified this was not an accurate description of the services provided for the resident, as the resident had not ambulated since February. She could offer no explanation as to why the NA was not able to accurately describe the services the resident received. At 9:20 a.m. on 04/22/15, upon inquiry, NA #1 said if the resident was to receive restorative AROM, the services were provided during the provision of daily care, such as bathing and dressing. She said the facility did not have time to provide individual restorative sessions or services on a daily basis. On 04/22/15 at 10:30 a.m., NA #5, the NA providing the daily care for Resident #913, was asked to describe the restorative services provided for Resident #913. NA #5 said the resident received AROM during the provision of her daily care. When asked if the resident received any other restorative services, the NA replied, She used to have restorative ambulation, but she quit walking, so that was discontinued. Upon further inquiry as to any other restorative services provided for the resident, she said, No. When asked about restorative transfer services, which were marked as completed, she said, We get her up in a chair. At 10:45 a.m. on 04/22/15, the DON was made aware of the responses given by the NAs regarding the restorative care for Resident #913. She verbalized she was at a loss for words. The DON said she could not understand why the NAs could not accurately describe the services they documented they had provided. | 2018-04-01 |
| 6231 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 311 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family interview, and staff interviews, the facility failed to ensure one (1) of six (6) residents reviewed for Activities of Daily Living (ADLs) was provided services to maintain and maximize the resident's functional ability. Prior to, and in the beginning of January 2015, the resident was able to perform most ADLs with limited assistance of one (1) staff member. The resident subsequently became dependent for her ADLs. She had declines in bed mobility, transfers, ambulation, dressing, eating, toilet use, personal hygiene, and bladder and bowel continence. Resident identifier: #913. Facility census: 38. Findings include: a) Resident #913 On 04/20/15 at 1:10 p.m., during an interview with the Medical Power of Attorney (MPOA) for Resident #931, the MPOA voiced concern over the resident's decline in health. The MPOA said the resident suffered a decline in her functional abilities. She said the resident used to walked in the facility using a walker, but had not walked in a few months. b) On 04/20/15 at 1:40 p.m. the resident's quarterly MDS, with an assessment reference date of 12/11/14, and the annual MDS with an ARD of 03/05/15 were reviewed. The review revealed declines in bed mobility, transfers, ambulation, dressing, eating, toilet use, personal hygiene, and bladder and bowel continence between the 12/11/14 and 03/05/15 assessments. Record review, on 04/20/14 at 1:40 p.m. found the following: 1. Quarterly MDS with an assessment reference date (ARD) of 12/11/14 Coding for G0110 indicated -- Bed mobility - coded 3/2 - indicating the resident required extensive assistance of one (1) staff member for the seven (7) day look back period. -- Transfers, Walk in room, Walk in corridor, Dressing, Toilet Use, and Personal Hygiene - coded 2/2 - indicating the resident required the limited assistance of one (1) staff member for the activity during the seven (7) day look back period. -- Eating - coded 0/1 - indicating the resident was independent and required only set-up assistance from staff during the seven (7) day look back period. Items H0300 and H0400 - indicated the resident was always continent of urine and bowel during the seven (7) day look back period. Item K0200 identified the resident's weight was 129 pounds Item K0300 indicated the resident had not had a weight loss of 5% or more in the last month or loss of 10% or more in the last six (6) months. 2. Annual MDS with an ARD of 03/05/15 Review of the next MDS, an annual assessment with an ARD of 03/05/15, found: Item G0110: -- Bed mobility, Transfers, Dressing, Eating, Toilet Use, and Personal Hygiene - coded 4/2 - indicating the resident required full staff performance of one (1) staff member for these activities during the seven (7) day look back period. -- Walk in room, Walk in the corridor - coded 8/8 - indicating the activity did not occur during the seven (7) day look back period. Items H0300 and H0400 indicated the resident was always incontinent of urine and bowel during the seven (7) day look back period. Item K0200 identified the resident weighed 113 pounds. Item K0300 indicated the resident did not have a weight loss of 5% or more in the last month or loss of 10% or more in the last six (6) months. (The prior assessment listed her weight 129 pounds. A weight of 113 represented a weight loss of 12.4% in 3 months). c) At 3:20 p.m., on 04/20/15, a review of Resident #931's Activities of Daily Living (ADL) tracking forms revealed declines in multiple areas. The ADL flow sheets indicated the resident was eating independently and only required set-up assistance from staff until 01/10/15. The ADL tracking forms from 01/10/15 through and including February, March, and April 2015, up to the time of review, indicated the resident had become totally dependent and required full assistance of one (1) staff member to eat. The resident's ability to transfer also began to decline in January of 2015. The ADL tracking forms indicated the resident was able to transfer with limited assistance of one (1) staff member until 01/28/15. Beginning 01/28/15, the tracking forms indicated the activity did not occur. In February, March, and April 2015, up to the time of review, the ADL tracking forms indicated either the activity did not occur, or when it occurred, the resident required extensive assistance of one (1) staff member. Resident #931's ability to walk in the room began to decline in January 2015. The ADL tracking forms indicated the resident was able to ambulate in her room with limited assistance of one (1) staff member until 01/15/15. Beginning 01/15/15, the flow sheets indicated the activity had not occurred. The ADL tracking forms indicated in February 2015 the resident had either required extensive assistance of one (1) staff member, or the activity had not occurred. In March of 2015, the tracking forms indicated the activity had not occurred. For the month of April 2015, the tracking forms indicated the activity had not occurred, up to the time of review. In January of 2015, the ADL tracking forms indicated the resident required limited assistance of one (1) staff member for dressing until 01/05/15, when she required extensive assistance of one (1) staff member. Beginning 01/20/15, the tracking forms indicated the resident was dependent for dressing and required the assistance of one (1) staff member. The months of February, March, and April 2015, up to the time of review, indicated the resident was dependent for dressing and required extensive assistance of one (1) staff member. The ADL tracking forms indicated the resident's ability to use the toilet required limited assistance of one (1) staff member until 01/04/15. The ADL tracking forms indicated beginning on 01/05/15, the resident required extensive assistance of one (1) staff member for toilet use. On 01/07/15 the ADL tracking form indicated the resident was dependent on one (1) staff member for toilet use. The ADL tracking form indicated the resident was continent of urine until 01/05/15. The ADL tracking forms indicated the resident was incontinent of urine for the remainder of January 2015, as well as February, March, and April 2015, up to the time of review. A review of the physician's orders [REDACTED]. 1. In January, February, March and April 2015 the resident had physician orders [REDACTED]. 2. In February of 2015, the resident had a physician's orders [REDACTED]. The restorative ambulation was marked as completed until the order was discontinued on 02/24/15. 3. Beginning on 02/25/15, the resident received restorative transfers, indicating the resident would transfer from the bed to a wheelchair with the assistance of one (1) staff member. The resident would bear weight and pivot. Both the restorative AROM and transfers were marked as completed for the remainder of February, March, and to the time of review in April 2015. On 04/21/15 at 11:45 a.m., Licensed Practical Nurse #19, upon inquiry as to the resident's functional decline, said the resident had been on antibiotics recently. She had not eaten well lately, and had a general overall decline in health. At 3:00 p.m. on 04/21/15, when asked to describe restorative services provided for Resident #913, Nurse Aide (NA) #1, the NA in charge of the restorative program, said the resident received AROM of her upper and lower extremities twice a day. She said the resident also received restorative ambulation, and the resident walked from her room to the dining room with staff assistance and the aide of a walker. When asked when she last provided these services for the resident, she said, It was one day last week, I can't remember the exact day, it was Wednesday or Thursday. On 04/21/15 at 4:00 p.m., the DON was made aware of NA #1's description of the restorative services provided for Resident #931. The DON verified this was not an accurate description of the services provided for the resident, since the resident had not ambulated since February. She could offer no explanation why the NA was not able to accurately describe the services the resident received. At 9:20 a.m. on 04/22/15, upon inquiry, NA #1 said the residents who required restorative AROM received the services during the provision of their daily care, such as bathing and dressing. She said the facility did not have time to provide individual restorative sessions or services on a daily basis. On 04/22/15 at 10:30 a.m., NA #5, the NA providing the daily care for Resident #913, was asked to describe the restorative services provided for Resident #913. NA #5 said the resident received AROM, which was provided during the provision of her daily care. When asked if the resident received any other restorative services, the NA replied, She used to have restorative ambulation, but she quit walking, so that was discontinued. Upon further inquiry as to any other restorative services provided for the resident, she said, No. When asked about restorative transfer services, which were marked as completed, she said, We get her up in a chair. At 10:45 a.m. on 04/22/15, the DON was made aware of the responses given by the NAs regarding the restorative care for Resident #913. She verbalized she was at a loss for words, and could not understand why the NAs could not accurately describe the services they documented they performed with the resident. | 2018-04-01 |
| 6232 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 315 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, the facility failed to ensure three (3) of four (4) residents observed for the provision of incontinence care were provided care in a manner to prevent, to the extent possible, urinary tract infections (UTIs). Resident identifiers: #913, #890, and #920. Facility census: 38. Findings include: a) Resident #913 On [DATE] at 2:15 p.m., a review of the physician's orders [REDACTED]. At 11:40 a.m. on [DATE], a review of the care plan for Resident #913 found no evidence in the current care plan, or resolved episodic care plans to indicate the resident had a history of [REDACTED]. On [DATE] at 11:10 a.m., during observation of the provision of incontinence care for Resident #913, Nurse Aide (NA) #60 gathered the needed supplies. This consisted of a basin of warm water, soap, towels, washcloths, a pair of gloves, and two (2) plastic trash bags. The resident was lying in her bed. The NA donned a pair of gloves without first washing her hands. She unsecured, and lowered the front of the resident's brief in order to provide care. The resident had had a large loose bowel movement. The NA used two (2) warm, soapy washcloths to remove the fecal matter from the resident's perineal area, and from the inner thighs, rinsing the washcloths in the basin of warm soapy water. She then assisted the resident onto her left side, and wiped the fecal matter from the resident's inner and outer buttocks, rinsing the washcloths in the basin of water. After removal of the visible fecal matter, she assisted the resident onto her back. The NA explained to the resident she was going to go change the water in the pan. She placed the soiled wash clothes into one (1) of the plastic bags. The NA carried the washbasin into the resident's bathroom, emptied the soiled water into the toilet, and flushed the commode. While still wearing the same pair of soiled gloves she had worn to remove the fecal matter from the resident, the NA turned on the water in the resident's sink, rinsed the washbasin, and refilled it with fresh water. NA #60 carried the basin back into the resident's room, and continued the provision of incontinence care while still wearing the same soiled gloves. She used one (1) clean washcloth, with downward [MEDICAL CONDITION], front to back. She cleansed the resident's inner thighs, rinsed the washcloth, and cleansed the resident's labial area. Observed on the washcloth, were small traces of fecal matter. The resident's legs remained flat on the bed and the NA did not separate the resident's labia while cleansing. She dried the resident's perineal area with a clean, dry towel. The NA again assisted the resident onto her left side and cleansed the resident's rectal area as well as the inner and outer buttocks, from the base of the labia outward, and dried the area with a towel. She removed the folded, soiled brief from beneath the resident, and placed it into the second plastic bag. NA #60 then placed a clean brief under the resident and assisted the resident onto her back. The NA secured the clean brief, and covered the resident. At 11:25 a.m. on [DATE], upon inquiry as to the manner in which the resident's labial area was cleaned, she verified she had not separated the labia to ensure proper cleansing of the area. She further verified she should have changed gloves and washed her hands prior to applying the clean brief. On [DATE] at 2:10 p.m., the Director of Nursing (DON) was made aware of the findings regarding the provision of incontinence care for Resident #913. The DON verified the incontinence care was not provided in a manner that would prevent the onset and spread of infection. The DON stated that education would be provided. A copy of the facility's incontinence care policy was requested at this time. A review of the facility's Incontinence Care policy found it included the following steps which had not been implemented when incontinence care was provided to Resident # 913: --Step 8. Instruct the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. --Step 9. For a female resident: b. 1. Separate labia and wash area from front to back, gently rinse and dry the area. b. 2. Continue to wash the perineum, moving from inside outward to an including the thighs, alternating from side to side, using downward [MEDICAL CONDITION]. Do not use the same washcloth or water to clean the urethra or labia. --Step 12. Remove gloves and discard into designated container. Wash and dry hands thoroughly (after the cleansing the resident, and prior to the application of a clean brief). At 9:45 a.m. on [DATE], review of the results of the UA and the completed C&S dated [DATE], obtained on [DATE], found the results indicated the resident had a UTI. The microorganism identified was Proteus mirabilis, (a normal part of the intestinal flora) with a colony count greater than 100,000. Upon physician notification on [DATE], the physician ordered an antibiotic, [MEDICATION NAME] 500 milligram (mg) by mouth three (3) times a day for seven (7) days. b) Resident #890 On [DATE] at 10:50 a.m., an order for [REDACTED].>At 11:05 a.m. on [DATE], a review of the physician progress notes [REDACTED].see typed notes. On [DATE] at 1:45 p.m., observation of incontinence care for Resident #890, by Nurse Aide (NA) #5, found the resident was on a prompted voiding program. The NA took the resident to the bathroom, where she provided incontinence care. The NA washed her hands and donned a clean pair of gloves. The NA lowered the resident's pants and pull-up brief, before assisting the resident to sit on the toilet. The NA then removed the resident's pants, and removed the wet pull-up brief from the resident. NA #5, readied two (2) warm soapy washcloths, and one (1) warm wet washcloth, then assisted the resident to a standing position. Resident #890 used the grab bar, located on the wall beside the toilet to maintain balance while standing. With the resident standing, the NA cleansed the resident's perineal area from front to back. She cleansed the resident's labial area first, separating the labia, and then cleansed the resident's inner thighs, and placed the soiled washcloths in a plastic bag for disposal. She used the warm wet washcloth to rinse the resident's perineal area and inner thighs, and then dried the areas with a dry towel. She placed the washcloth and the towel in the bag for disposal. The NA then assisted the resident to sit back down on the toilet while she applied a clean, dry, pull-up brief, as well as the resident's pants. At 2:00 p.m. on [DATE], upon inquiry regarding hand washing and the proper use of gloves, NA #5 said she should have removed her gloves, washed her hands, and applied a clean pair of gloves, before she had applied the clean pull-up brief and the resident's pants. A review of the facility's Incontinence Care policy found it included the following steps which had not been implemented when incontinence care was provided to Resident #890: --Step 12. Remove gloves and discard into designated container. Wash and dry hands thoroughly (after the cleansing the resident, and prior to the application of a clean brief). --Step 17. Wash and dry thoroughly (after the completion of the provision of incontinence care, prior to leaving the resident's room). On [DATE] at 2:15 p.m., the DON was made aware of the findings regarding the provision of incontinence care for Resident #890. The DON verified the incontinence care was not provided in a manner that would prevent the onset and spread of infection, nor did the NA follow the facility's Incontinence Care policy. c) Resident #920 Review of Resident #920's medical at 10:28 a.m. on [DATE], found the resident's care plan addressed the resident's bowel and bladder incontinence. The goal was for the resident to be free from skin break down related to incontinence. Interventions included incontinent care every two (2) hours and as needed. Review of the Resident #920's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], found the resident was always of incontinent of bowel and bladder. On [DATE], the physician ordered a urinalysis. After receiving the results of the UA, the physician ordered the antibiotic [MEDICATION NAME] 1 gram intramuscularly for three (3) days due to a UTI. Resident #920 had another urinalysis on [DATE]. Based on the results of this urinalysis, the physician ordered Resident #920 started on [MEDICATION NAME] 100 milligrams twice daily due to a urinary tract infection. On [DATE] at 11:20 a.m., the provision of incontinence care for Resident #920, provided by Nurse Aide (NA) #27, was observed. The NA had gathered the supplies needed to provide incontinence care for the resident. NA #27 then washed her hands and donned a pair of gloves. She placed a package of cleansing wipes directly on the over-the-bed table, and pulled six (6) of the wipes free from the package. The wipes pulled from the package, were placed on top of the package. Also observed on the resident's over-the-bed table was an opened package, which contained the syringe used with the resident's enteral feeding system. Resident #920 was lying on her bed. Using one (1) of the wipes, the NA separated the resident's labia and began cleansing, one (1) swipe, downward from front to back. Fecal smears were observed on the cleansing wipe. The NA placed the wipe in the plastic bag located on the resident's over-bed table. The NA repeated these steps with three (3) more cleansing wipes, until the wipes no longer had fecal smears. NA #27, using another of the cleansing wipes, wiped the resident's inner left thigh area, then placed the cleansing wipe in the plastic bag. She repeated this step with the remaining cleansing wipes she had pulled from the package. She then opened the package, and retrieved the remaining wipes from the package, cleansed the resident's inner right thigh area. She placed the contaminated wipes, as well as the empty cleansing wipe package, in the plastic bag on the resident's over-he-bed table. NA #27, then explained to Resident #920, that she needed to go and get another package of wipes. She pulled the sheet up and over the resident. She then removed her contaminated gloves and placed them in the plastic bag. She exited the room without washing her hands. She returned with a new package of cleansing wipes, and placed the package on the over-the-bed table. Without washing her hands, she donned a clean pair of gloves and removed six (6) cleansing wipes from the new package, and placed them on top of the package. NA #27 then assisted Resident #920 onto her left side. Using two (2) cleansing wipes, the NA wiped from the base of the labia, over the buttocks. Fecal smears were observed on the cleansing wipes. She placed the soiled wipes in the plastic bag on the over-bed table. The plastic bag was observed quite full of contaminated cleansing wipes, as well as the empty wipes package, leaving little room for additional contaminated materials. She repeated the steps of cleansing the resident's buttocks, with the remaining four (4) cleansing wipes, and placed the soiled wipes in the plastic bag. While still wearing the contaminated gloves, she opened the package containing the cleansing wipes and retrieved four (4) more wipes. Again using the remaining four (4) wipes, separately, she finished cleansing the resident's buttocks area. At 11:40 a.m. on [DATE], upon inquiry, NA #27 verified she had not washed her hands upon removing the contaminated gloves prior to leaving the room to retrieve more cleansing wipes. She further verified she had not washed her hands after reentering the resident's room with the new package of cleansing wipes. When asked what potential problems could occur as a result of opening the package containing the cleansing wipes, to pull free additional wipes, while wearing contaminated gloves, she said it would contaminate the packaging as well as the wipes that remained inside of the package. At 12:00 p.m., on [DATE], the DON was made aware of the observation of incontinence care for Resident #920. The DON verified the incontinence care was not provided in a manner that would prevent the onset and spread of infection. | 2018-04-01 |
| 6233 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 325 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family interview, and staff interview, the facility failed to ensure one (1) of six (6) residents reviewed maintained acceptable parameters of nutritional status. The resident's weight loss was not assessed for necessary changes in the resident's plan of care. In addition, the plan of care was not implemented and/or evaluated as the resident experienced continual weight losses. The facility also failed to effectively monitor and track the nutritional supplements provided to the resident. Between December of 2014 and April of 2015, the resident had a cumulative weight loss of 17.65% of her total body weight. Resident identifier: #913. Facility census: 38. Findings include: a) Resident #913 Medical record review revealed Resident #913 experienced the following weight losses, between the month of December of 2014 through the month of April of 2015: -- From 12/04/14 to 01/04/15, the resident lost 10 pounds (#), from a weight of 129.2 # to 119.2 #. This was 7.74% of her body weight in one (1) month, a severe weight loss. -- From 01/04/15 to 02/04/15, the resident lost 7.6 #, from a weight of 119.2 # to 111.6 #. This was another severe weight loss. Between 12/04/14 and 02/04/15, the resident lost 13.62% of her total body weight. -- From 02/04/15 to 03/04/15, the resident gained 1 #, from a weight of 111.6 # to 112.6 #, reducing the total weight loss in three (3) months to 12.85%, which still represented a severe weight loss. -- From 03/04/15 to 04/04/15, the resident lost another 6.2 #, from a weight of 112.6 # to 106.4 #. This was another severe weight loss (5.5%) in one (1) month. The weight loss from 129.2 on 12/04/14 to the last available weight of 106.4 on 04/04/15 represented a cumulative severe total body weight loss of 17.65% in four (4) months. The percentage of weight losses were calculated using the following formula: % of body weight loss = (usual weight-actual weight) / (usual weight) X 100. (The resident's last identified stable weight was used as the resident's usual body weight.) On 04/20/15 at 1:10 p.m., the resident was lying in bed. Her Medical Power of Attorney (MPOA) was seated beside her. The resident's noon meal tray was on the resident's over-the-bed table. The meal consisted of three (3) types of uneaten pureed foods. Upon inquiry, the MPOA said Resident #913 had only taken a couple of bites. The MPOA said the resident's appetite was very poor in the past few months, and the resident was losing weight. The MPOA said the resident normally received a Magic Cup (a nutritional supplement) with meals, but she had not received one today. She said a staff member told her the facility was out of the Magic Cups, and they would have them tomorrow. A Great Shake, a nutritional supplement, was on the resident's meal tray. Upon inquiry, the MPOA said the resident had not consumed any of the Great Shake because she did not care for them. The MPOA said the facility offered different flavors, but the resident normally did not care for any of the flavors and rarely drank the Great Shakes. A record review, on 04/20/15 at 1:40 p.m., revealed a quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/11/14. Section G0110 was reflected the following: -- h. Eating 0/1 - this indicated the resident was independent and required only set-up assistance from staff during the seven (7) day look back period. Section K0200 indicated: -- b. Weight - 129 pounds Section K0300 indicated a weight loss of five (5)% or more in the last month or loss of ten (10)% or more in the last six (6) months, had not occurred. Section K0510, Nutritional approaches, indicated the resident received a therapeutic diet and did not receive a mechanically altered diet. The next MDS assessment with an ARD of 03/05/15, was an annual assessment: Section G0110 reflected: --h. Eating 4/2 - this indicated the resident was total dependence for eating and required full staff performance of one (1) staff member for the seven (7) day look back period. Section K0200 reflected: --b. Weight - 113 pounds Section K0300 indicated a weight loss of five (5)% or more in the last month or loss of ten (10)% or more in the last six (6) months had not occurred. Section K0510, Nutritional approaches, indicated the resident received a therapeutic diet and did not receive a mechanically altered diet. At 2:15 p.m. on 04/20/15, a review of the physician's orders [REDACTED]. No order was found for a mechanically altered diet. A review of the resident's meal consumption percentages, on 04/20/15 at 3:20 p.m., for the months of January, February, March, and April 2015 identified the following percentages consumed by the resident: -- January 2015 - 93 meals were served to the resident. She refused 13 meals, consumed 25% of 49 meals, 50% of 28 meals, and 75% of two (2) meals. The dinner meal on 01/21/15, was left blank. -- February 2015 - 84 meals were served to the resident. She refused ten (10) meals, consumed 25% of 39 meals, 50% of 19 meals, and 75% of six (6) meals. There were ten (10) meals served in which the percentage consumed had been left blank. -- March 2015 - 93 meals were served to the resident. She refused seven (7) meals, consumed 25% of 71 meals, 50% of 14 meals, and 75% of one (1) meal. -- April 2015 - 60 meals were served to the resident at the time of review. She refused eight (8) of the meals, consumed 25% of 44 meals, 50% of 8 meals, with 50% being the largest amount consumed. On 04/21/15 at 9:00 a.m., a review of the resident's weights identified the following weights: --12/04/14 - 129.2 # --01/04/15 - 119.2 # --02/04/15 - 111.6 # --03/04/15 - 112.6 # --04/04/15 - 106.4 # At 9:05 a.m. on 04/21/15, a review of the Treatment Administration Record (TAR) for April 2015, and the previous two (2) months, identified two (2) nutritional supplements. -- 1. Great Shakes to be given with meals, was ordered on [DATE]. The shakes were marked as refused 27 times during the month of February for the dinner meal, 25 times during the month of March for the dinner meal, and 180 milliliters (ML) consumed, for all other times offered. The shakes offered in April of 2015 were all marked as 180 ml consumed. -- 2. Magic Cup to be given with lunch and dinner, was ordered on [DATE]. The TAR's from the date ordered through the time of review, indicated the Magic cups were provided to the resident; however, the amount consumed by the resident was not indicated. On 04/20/15, the TAR indicated the resident received a Magic Cup with lunch and dinner. This was the day the resident's MPOA reported the resident did not receive a Magic Cup with her lunch, because the facility was out of them. During an interview with Nurse Aide (NA) #41, on 04/21/15 at 9:10 a.m., she was asked to describe the method used to track the resident's consumption of the nutritional supplement, Magic Cup. The NA said it was counted as part of the resident's meal consumption percentage. A review of the physician's progress notes, on 04/21/15 at 9:35 a.m., identified a note written on 02/18/15. The physician noted the resident refused her health shakes and had lost weight. The last dietary progress notes, dated 12/11/14, were reviewed on 04/21/15 at 11:00 a.m. They indicated a weight of 129#. Her oral intake was fair to good at the time of the entry. On 04/21/15 at 2:10 p.m., the Director of Nursing (DON) and the Registered Dietitian (RD), upon inquiry as to the method used to track the resident's consumption of the nutritional supplement, Magic Cups, stated the percentage was tracked on the TAR. Both were made aware staff reported the nutritional supplements were part of the meal consumption tracking. Both agreed this was not an effective way to accurately monitor the amount of the supplement which was consumed. Both the DON and RD were asked if the facility changed diet orders, from regular consistency to other consistencies, without a physician's orders [REDACTED]. They were asked to provide the order for Resident #913 to receive pureed foods, but were unable to locate an order in the resident's medical record. The RD said she would look in the kitchen. The RD was asked if the facility had been out of the nutritional supplement Magic Cups recently. She stated they had not had any in the facility on 04/20/15, but they were now available and had been provided to the residents as of 04/21/15. The DON and RD were made aware the Magic Cups ordered for lunch and dinner on 04/20/15 were marked as provided on the resident tracking forms. Both the DON and RD were unable to provide an explanation as to why the supplements were marked as provided, when the facility had none to provide. Upon review of the resident's weights with the RD and the DON, the RD said she had somehow missed the weight of 111.6# which was obtained on 02/04/15. The RD agreed this resulted in a failure to identify the significance of the resident's weight loss. At 3:30 p.m. on 04/21/15, the RD provided an undated communication slip indicating a diet change for the resident. The diet change was for pureed foods. The RD verified an order for [REDACTED]. On 04/22/15 at 1:20 p.m., the resident was observed in the dining room for the noon time meal. The resident was observed with a diet of regular consistency. | 2018-04-01 |
| 6234 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 367 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family interview, and staff interview, the facility failed to ensure one (1) of six (6) residents reviewed was provided foods in the form prescribed by the physician. The resident received a pureed diet without an order for [REDACTED].#913. Facility census: 38 Findings include: a) Resident #913 On 04/20/15 at 1:10 p.m., the resident was lying in bed. Her Medical Power of Attorney (MPOA) was seated beside her. The noon meal tray for the resident was on the resident's over-the-bed table. The tray consisted of three (3) types of pureed foods. A review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/11/14, and the annual MDS assessment with an ARD of 03/05/15, on 04/20/15 at 1:40 p.m., found both indicated only that the resident had received a therapeutic diet. Neither MDS assessment indicated the resident received a mechanically altered diet. At 2:15 p.m. on 04/20/15, a review of the physician's orders revealed an order, dated 11/14/13, for a therapeutic diet of no added salt (NAS). There was not an order for [REDACTED]. On 04/21/15 at 2:10 p.m., the Director of Nursing (DON) and the Dietitian were asked if the facility changed diet orders, from regular consistency to other consistencies, without a physician's order. Both replied saying, there would have to be an order to change a diet. Both were asked to provide the order for Resident #913 to receive pureed foods. When both were unable to locate an order in the resident's medical record, the dietitian said she would look in the kitchen. At 3:30 p.m. on 04/21/15, the Dietitian provided an undated communication slip indicating a diet change for the resident. The diet change was for pureed foods. The Dietitian verified there was no physician's order to change resident's diet consistency. She further verified the resident should not have received a mechanically altered diet without an order. On 04/22/15 at 1:20 p.m., observations found the resident in the dining room for the noontime meal. The resident had a diet of regular consistency. | 2018-04-01 |
| 6235 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 441 | D | 1 | 0 | 0UGG11 | Based on observation, staff interview, and policy review, the facility failed to maintain an Infection Control Program to prevent, to the extent possible, the onset and spread of infections for three (3) of four (4) residents observed for the provision of incontinence care. Observations revealed omissions of handwashing and the improper use of gloves. In addition, staff failed to provide incontinence care and perineal care in a manner to prevent potential infections and disease transmission. Resident identifiers: #913, #890, and #920. Facility census: 38. Findings include: a) Resident #913 On 04/21/15 at 11:10 a.m., the resident's provision of incontinence care, provided by Nurse Aide (NA) #60, was observed. The NA gathered her supplies, consisting of a basin of warm water, soap, towels, washcloths, a pair of gloves, and two (2) plastic trash bags. The resident was lying in bed. The NA donned gloves without first washing her hands. She unfastened and lowered the front of the resident's brief to provide care. Observation revealed the resident had a large loose bowel movement. The NA used two (2) warm, soapy washcloths to remove the fecal matter from the resident's perineal area and inner thighs. She rinsed the washcloths in the basin of warm soapy water. The NA then assisted the resident onto her left side, and wiped the fecal matter from the resident's inner and outer buttocks, then rinsed the washcloths in the basin of water. After removing the visible fecal matter, the NA assisted the resident onto her back, and explained to the resident that she was going to go change the water in the pan. She placed the soiled washcloths into one (1) of the plastic bags. The NA carried the washbasin into the resident's bathroom, emptied the soiled water into the toilet, and flushed the toilet. While still wearing the same pair of soiled gloves she wore to remove the fecal matter from the resident, the NA turned on the water in the resident's sink, rinsed the washbasin, and refilled the basin with fresh water. NA #60 carried the basin back into the resident's room, and continued the provision of incontinence care. Still wearing the same soiled gloves, the NA resumed the provision of care. She used one (1) clean washcloth, in downward strokes, front to back, cleansed the resident ' s inner thighs, rinsed the washcloth, and cleansed the resident's labial area. Observation of the washcloth revealed small traces of fecal matter. The resident's legs remained flat on the bed, and the NA did not separate the resident's labia while cleansing. She dried the resident's perineal area with a clean, dry towel. The NA again assisted the resident onto her left side and cleansed the resident's rectal area as well as the inner and outer buttocks, from the base of the labia outward, then dried the area with a towel. She removed the folded, soiled brief from beneath the resident, and placed it into the second plastic bag. NA #60 then placed a clean brief under the resident and assisted the resident onto her back. The NA secured the clean brief, and covered the resident. NA #60 again carried the washbasin into the resident's bathroom. This time she emptied the contents of the basin into the resident's sink. While still wearing the same soiled gloves, she turned on the water and rinsed the washbasin. She dried the basin, and returned it to the resident's closet. The NA then returned to the resident's bathroom, removed her gloves, and washed her hands. At 11:25 a.m. on 04/21/15, upon inquiry regarding the use of gloves, NA #60 said she should have removed her gloves prior to turning on the water in the resident's bathroom, . because I contaminated the sink. When asked about the dirty water she emptied into the sink, she said, I contaminated the sink with that too. I should have emptied it into the toilet. Upon inquiry, the NA verified she did not separate the labia to ensure proper cleansing of the area. She further verified she should have changed gloves and washed her hands prior to applying the clean brief. On 04/21/15 at 2:10 p.m., the Director of Nursing (DON) was made aware of the findings regarding the provision of incontinence care for Resident #913. The DON verified the incontinence care was not provided in a manner to prevent the onset and spread of infection. The DON stated education would be provided. A copy of the facility's incontinence care policy was requested. A review of the facility's Incontinence Care policy found it included the following steps which were not implemented when incontinence care was provided to Resident # 913: --Step 8. Instruct the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. --Step 9. For a female resident: b. 1. Separate labia and wash area from front to back, gently rinse and dry the area. b. 2. Continue to wash the perineum, moving from inside outward to an including the thighs, alternating from side to side, using downward strokes. Do not use the same washcloth or water to clean the urethra or labia. --Step 12. Remove gloves and discard into designated container. Wash and dry hands thoroughly (after the cleansing the resident, and prior to the application of a clean brief). --Step 17. Wash and dry hands thoroughly. This step is to be completed after cleaning the wash basin and returning it to the designated storage place. b) Resident #890 On 04/22/15 at 1:45 p.m., the provision of incontinence care for Resident #890, provided by Nurse Aide (NA) #5, was observed. Resident #890 was on a prompted voiding program; therefore, the observation was in the resident's bathroom. The NA took the resident to the bathroom, washed her hands, and donned a clean pair of gloves. The NA lowered the resident's pants and pull-up brief, then assisted the resident to sit on the toilet. The NA then removed the resident's pants, and removed the wet pull-up brief from the resident. NA #5 prepared two (2) warm soapy washcloths and one (1) warm washcloth, then assisted the resident to a standing position. Resident #890 used the grab bar, located on the wall beside the toilet, to maintain balance while standing. With the resident standing, the NA cleansed the resident's perineal area from front to back. She cleansed the resident's labial area first, separating the labia, and then cleansed the resident's inner thighs, and placed the soiled washcloths in a plastic bag for disposal. She then used the warm, wet washcloth to rinse the resident's perineal area and inner thighs, she then dried the areas with a dry towel. She placed the washcloth and the towel in the bag for disposal. The NA assisted the resident to sit back down on the toilet while she applied a clean, dry, pull-up brief, as well as the resident's pants. While still wearing the same pair of soiled gloves, the NA reached out to the resident, clasped both of the resident ' s hands in her contaminated, gloved hands, and assisted the resident to a standing position. Once the resident stood up, the NA pulled the resident's pull-up brief and pants into position. The NA removed her right glove and left the room carrying the bag containing the contaminated items in her gloved left hand. She went to the soiled utility room and with her ungloved hand, opened the door to the soiled utility room and placed the bag containing the soiled linens into a container. She then removed and disposed of the soiled glove and washed her hands. The NA wore the same pair of gloves for the entirety of the provision of care and disposal of the soiled linens and pull-up brief. During the observation, the NA only washed her hands prior to the provision of care and after the disposal of the soiled articles. At 2:00 p.m. on 04/22/15, upon inquiry regarding handwashing and the proper use of gloves, NA #5 said she should have removed her gloves, washed her hands, and applied a clean pair of gloves before she applied the clean pull-up brief and the resident's pants. The NA said she should not have held the hands of Resident #890, while wearing the gloves she had worn for the provision of incontinence care, because, I contaminated her hands. Review of the facility's Incontinence Care policy found it included the following steps which were not implemented when incontinence care was provided to Resident #890: --Step 12. Remove gloves and discard into designated container. Wash and dry hands thoroughly (after the cleansing the resident, and prior to the application of a clean brief). --Step 17. Wash and dry thoroughly (after the completion of the provision of incontinence care, prior to leaving the resident's room). On 04/22/15 at 2:15 p.m., the DON was made aware of the findings regarding the provision of incontinence care for Resident #890. The DON verified the incontinence care was not provided in a manner that would prevent the onset and spread of infection, nor did the NA follow the facility's Incontinence Care policy. c) Resident #920 On 04/23/15 at 11:20 a.m., the provision of incontinence care for Resident #920, provided by Nurse Aide (NA) #27, was observed. The NA had gathered the supplies needed to provide incontinence care for the resident. The NA opened a plastic bag and placed it directly on the resident's over-the-bed table, using no barrier to protect the surface of the table from contamination. NA #27 then washed her hands and donned a pair of gloves. She placed a package of cleansing wipes directly on the over-the-bed table, and pulled six (6) of the wipes free from the package. The wipes pulled from the package were placed on top of the package. Also observed on the resident's over-bed table was an opened package, which contained the syringe used with the resident's enteral feeding system. Resident #920 was lying in bed. Using one (1) of the wipes, the NA separated the resident's labia and cleansed the resident using one (1) swipe downward from front to back. Fecal smears were observed on the cleansing wipe. The NA placed the wipe in the plastic bag located on the resident's over-the-bed table. The NA repeated these steps with three (3) more cleansing wipes, until the wipes no longer had fecal smears. NA #27 using another of the cleansing wipes, wiped the resident's inner left thigh area, and then placed the cleansing wipe in the plastic bag. She repeated this step with the remaining cleansing wipes she had pulled from the package. She then opened the package, retrieved the remaining wipes from the package, and cleansed the resident's inner right thigh area. She placed the contaminated wipes, as well as the empty cleansing wipe package, in the plastic bag on the resident's over-the-bed table. NA #27 then explained to Resident #920, that she needed to go and get another package of wipes. She pulled the sheet over the resident. She then removed her contaminated gloves and placed them in the plastic bag. The NA exited the room without washing her hands. She returned with a new package of cleansing wipes and placed the package on the over-the-bed table. Without washing her hands, she donned a clean pair of gloves, removed six (6) cleansing wipes from the new package, and placed them on top of the package. NA #27 then assisted Resident #920 onto her left side. Using two (2) cleansing wipes, the NA wiped from the base of the labia over the buttocks. Fecal smears were observed on the cleansing wipes. She placed the soiled wipes in the plastic bag on the over-the-bed table. The plastic bag was quite full of contaminated cleansing wipes, as well as the empty package of wipes, leaving little room for additional contaminated materials. The NA repeated the steps of cleansing the resident's buttocks with the remaining four (4) cleansing wipes, and placed the soiled wipes in the plastic bag. While still wearing the contaminated gloves, she opened the package containing the cleansing wipes and retrieved four (4) more wipes. Using the remaining four (4) wipes, she finished cleansing the resident's buttocks area. The NA placed each of the contaminated wipes onto the other contaminated material in the plastic bag. The bag was no longer effective in containing the contaminated contents. The opening of the plastic bag was in direct contact with the over-the-bed table. Some of the contaminated contents were not fully inside of the bag. They were in direct contact with the surface of the over-the-bed table. NA #27 again covered the resident after completing the provision of care, explaining that she was going to give the resident a shower. The NA stated she was going to dispose of the bag containing the soiled materials first. She gathered and removed the bag from the over-the-bed table for disposal. The NA removed her gloves and washed her hands. The NA then exited the resident's room. At 11:40 a.m. on 04/23/15, upon inquiry regarding the placement of the bag used to contain the contaminated materials, the NA said she normally placed the bag on the floor. She said she was unsure what prompted her to place the bag on the resident's over-the-bed table. When asked what potential problems she could identify as a result of the placement on the over-the-bed table, the NA replied, It could spread germs to her feeding tube equipment. She verified she did not wash her hands upon removing the contaminated gloves prior to leaving the room to retrieve more cleansing wipes. The NA further verified she did not wash her hands after reentering the resident's room with the new package of cleansing wipes. The NA confirmed retrieving cleansing wipes while wearing contaminated gloves contaminated the packaging as well as the wipes that remained inside of the package. At 12:00 p.m., on 04/23/15, the DON was made aware of the finding regarding the observation of incontinence care for Resident #920. The DON verified the incontinence care was not provided in a manner to prevent the potential for the development and spread of infection. | 2018-04-01 |
| 6236 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 502 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain timely laboratory services for one (1) of six (6) sampled residents. The results of an ordered sputum culture and sensitivity (C&S) laboratory test were not obtained for eight (8) days after the specimen was obtained. Resident identifier: #927. Facility Census: 38. Findings include: a) Resident #927 On 04/23/15 at 10:25 a.m., a review of the physician's orders [REDACTED]. At 1:00 p.m. on 04/23/15, a review of the nurses' notes identified an entry written on 04/22/15 at 5:00 p.m. The note indicated the results from the sputum culture were obtained, and the physician was notified of the results. Upon notification of the results, on 04/22/15, the physician ordered a continuation of the antibiotic, [MEDICATION NAME] 100 milligrams twice a day for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA), until 04/24/15, then to continue at the same dosage for four (4) more days. The physician also wrote an order to start respiratory isolation precautions due [MEDICAL CONDITION]. On 04/23/15 at 1:17 p.m., Registered Nurse (RN) #42, was asked when and how the results of the sputum culture, ordered and obtained on 04/14/15, were received. RN #42 stated when the physician was in the facility on 04/22/15, he inquired about the results of the sputum culture he ordered on [DATE]. RN #42 said when she was unable to locate the results, she called the laboratory and had the results faxed to the facility for review by the physician. RN #42 confirmed, after reviewing the results the physician wrote orders to continue the [MEDICATION NAME] and to start respiratory precautions [MEDICAL CONDITION]. At 2:40 p.m. on 04/23/15, the Director of Nursing (DON) was made aware of how and when the lab results were obtained. She said her expectation and facility practice was to call the laboratory for the results if the results were not received the third day after sending a specimen. The DON said the time frame that elapsed in this situation was not acceptable. She said nursing staff should have monitored the situation better. On 04/23/15 at 3:44 p.m., the DON verified the laboratory failed to send the results and the facility dropped the ball when they did not attempt to locate the results, until the physician requested to review them. | 2018-04-01 |
| 6237 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 514 | D | 1 | 0 | 0UGG11 | Based on resident observation, record review, and staff interview, the facility failed to ensure one (1) of six (6) residents on the sample had a complete and accurate medical record. Observations found the resident required extensive assistance from staff to transfer; however, documentation on the Activities of Daily Living (ADL) flow sheet, indicated she was totally dependent on staff for transfers. Resident identifier: #920. Facility Census: 38. Findings Include: a) Resident #920 At 10:45 a.m. on 04/22/15, observation revealed Resident #920 being transferred from her bed to her Geri-Chair. Nurse Aide (NA) #12 assisted the resident in the transfer. The resident was assisted to the standing position and was then pivoted to her Geri-Chair. An interview with NA #12, at 1:00 p.m. on 04/22/15, confirmed the resident assisted with the transfer. NA #12 confirmed Resident #920 was able to stand up, bear weight, and assist with the transfer. A review of Resident #920's ADL flow sheet related to transferring, at 9:00 a.m. on 04/23/15, found on 04/22/15 during day shift, documentation indicated the resident was being totally dependent (full staff performance) with transfers with the assist of one (1) person. An interview with the Director of Nursing (DON) at 9:30 a.m. on 04/23/15, confirmed if Resident #920 was able to bear weight and assist with the transfer, then she was not totally dependent. She stated the documentation should have indicated the resident needed extensive assistance with transfers. | 2018-04-01 |
| 6238 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 161 | E | 0 | 1 | EXXT11 | Based on financial 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 total amount of residents' funds as of the most recent quarter. This had the potential to affect all residents with a resident trust fund account with the facility. Fifty (50)residents had a personal funds account with the facility. Facility census: 50. Findings include: a) On 08/12/14 at 10:00 a.m. a review of the resident funds on deposit revealed the most recent quarterly balance, according to the Account Summary, was April 2014: $16,595.24; May 2014: $15,030.23; and June 2014: $16,655.19. The facility's current surety bond was for $10,000.00. The bond was insufficient to cover the resident trust fund accounts of the fifty (50) residents who had a trust fund account with the facility. b) On 08/12/14 at 10:30 a.m., an interview was conducted with Employee #100 (Business Office staff). Employee #100 acknowledged the account summary balances for the most recent quarter had exceeded the amount of the current surety bond. | 2018-04-01 |
| 6239 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 253 | E | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to ensure effective housekeeping and maintenance services to maintain a sanitary, orderly, comfortable interior which was free from esthetic imperfections. Observations of resident rooms found multiple pieces of spackling was missing and broken, entrance doors had multiple scratches or mars or chipped wood, dresser finishes were scratched and sometimes down to the bare wood, knobs were missing on dressers, wooden bed rails were scratched and marred, a closet door had a hole through the wood, shower floor tiles contained a black substance, shower wall tiles contained a black substance, tile and caulking was discolored around a commode, and a rusted and dirty heating and cooling unit was observed. These findings were observed in thirteen (13) of twenty-four (24) resident rooms in Stage I of the Quality Indicator Survey. Room numbers: A100, A102, A107, A108, B100, B101, B103, B105, B107, B108, B109, C102 and C108. Resident census: 50. Findings include: a) A Hall A tour was conducted with Environmental Employees #98 and #96 on 08/11/14 between 11:00 a.m. and 12:00 p.m. The findings for esthetic imperfections were as follows: - Room 100. The closet door contained multiple scratches. - Room 102. The finish of the entrance door had deep scrapes down into the wood. There were multiple scrapes on the wooden part of the bed side rails. - Room 107. The white paint was scraped off the inner and outer bathroom door trim in several areas. It had black/brown discoloration in place of the white paint. Two (2) knobs were missing from a dresser in the room. - Room 108. Two (2) knobs were missing from a dresser in the room. b) B Hall A tour was conducted with Environmental Employees #98 and #96 on 08/11/14 between 11:00 a.m. and 12:00 p.m. The findings for esthetic imperfections and areas of uncleanliness were as follows: - Room 100. A dresser in the room was scratched down to the bare wood, and one (1) knob was missing. The closet door contained a hole broken through the wood. The wooden bed rails had multiple scrapes on the finish. - Room 101. A dresser had multiple scrapes, and in some places the bare wood was exposed. The shower tiles contained a large amount of black colored substance around the perimeter of the shower, and up a little on the lower part of the shower wall. The tile and caulking around the commode was discolored. The finish of the wooden bed was scraped in multiple areas. - Room 103. The wooden trim of both beds had multiple scrapes. The heating and cooling unit was dirty and rusted. - Room 105. The wooden dressers in the room had multiple scratches and scrapes. The shower tiles contained a black substance. The entrance door into the room had scrapes and scratches. The wooden trim of Bed A had multiple scrapes and scratches in the finish. - Room 107. The dresser had scrapes with bare wood exposed. The wooden trim of the beds were scraped in multiple areas. The entrance door had multiple scrapes and scratches. - Room 108. The wooden trim of the beds were scraped and scratched in multiple areas. - Room 109. The wooden trim of the beds were scraped and scratched in multiple areas. A dresser was scratched with bare wood exposed. The entrance door had deep gouges in it. c) C Hall A tour was conducted with Environmental Employees #98 and #96 on 08/11/14 between 11:00 a.m. and 12:00 p.m. The findings for esthetic imperfections are as follows: - Room 102. Multiple pieces of spackling were broken and missing around the closet wall. The entrance door contained multiple deep scratches. - Room 108. The entrance door was scraped and marred in numerous small areas. The wood was chipped at the lower part of the entrance door facings. During an interview with the Person in Charge, Employee #31, on 08/14/14 at 2:00 p.m., she said she did walking rounds monthly on all the units. She said she recently turned in some work orders, and work was due to begin in one (1) or two (2) working days. She said they had plans to work on one (1) unit at a time until all three (3) units were completed with the requests. A copy of the work orders was not provided or observed. | 2018-04-01 |
| 6240 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 256 | D | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and medical record review, the facility failed to ensure the provision of adequate and comfortable lighting for one (1) of twenty-four (24) residents observed in Stage I of the Quality Indicator Survey. A resident with known visual impairment lacked the necessary lighting she felt she needed in order to see and read more easily while in bed. Resident identifier: #2. Facility census: 50. Findings include: a) Resident #2 During an interview on 08/05/14 at 4:22 p.m., Resident #2 stated, I like to read and the light is not bright enough. Told the nurse. An observation of the resident's room, during the environmental tour on 08/11/14, at approximately 11:00 a.m., revealed the light over her bed was on and put off a fair amount of light. Resident #2 said she preferred more light. She told the maintenance crew during this environmental tour she would like to have more light to read by. She also said she told a nurse about it, but could not remember the nurse's name. She said she told everyone. The resident's medical record was reviewed on 08/12/14 at 10:00 a.m. The most recent minimum data set (MDS), with an assessment reference date (ARD) of 07/07/14, assessed this resident had a [DIAGNOSES REDACTED]. A leisure interest assessment, dated 04/03/14, assessed the resident did in room activities (reading, radio, television) with the comment, can't see well to read. The MDS nurse, Employee #15, was interviewed on 08/12/14 at 11:45 a.m. She said she had not heard this resident ask or say anything about her lighting. She was aware this resident had a history of [REDACTED]. An interview was conducted with the Person in Charge, Employee #31, on 08/12/14 at 2:15 p.m. She said it would help if the resident would allow the staff to draw her curtains, but she generally did not want the curtains opened. Employee #31 said she would see about getting a separate light for Resident #2's room. | 2018-04-01 |
| 6241 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 279 | D | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to develop a care plan based on the comprehensive assessment for one (1) of fourteen (14) Stage 2 sampled residents. A resident who had a [DIAGNOSES REDACTED]. Resident identifier: #2. Facility census: 50. Findings include: a) Resident #2 During an interview on 08/05/14 at 4:22 p.m., Resident #2 stated, I like to read and the light is not bright enough. Told the nurse. Observations were made during the environmental tour on 08/11/14 at approximately 11:00 a.m. The light over her bed was on and put off a fair amount of light, but she said she preferred more light. She told the maintenance crew during the environmental tour she would like to have more light to read by. She said she told a nurse about it, but could not remember the nurse's name. She said she told everyone. The resident's medical record was reviewed on 08/12/14 at 10:00 a.m. The most recent minimum data set (MDS), with an assessment reference date (ARD) of 07/07/14, assessed this resident had a [DIAGNOSES REDACTED]. A leisure interest assessment, dated 04/03/14, assessed that the resident did in room activities (reading, radio, television), with the comment, can't see well to read. The MDS nurse, Employee #15, was interviewed on 08/12/14 at 11:45 a.m. She said she had not heard this resident ask or say anything about her lighting. She was aware this resident had a history of [REDACTED]. The MDS nurse printed off a quarterly nurse assessment. Quarterly assessments included side rail, dental, vision, pain, and various types of assessments the facility completed quarterly on each resident. The vision assessment, dated 07/04/14, addressed the resident had vision problems and wore glasses. It noted her pupils were equal but slow to react, and that the resident reported a history of cataract surgeries on both eyes. The care plan was reviewed. It contained nothing about her vision problems. There were no problem areas related to vision, or goals the resident and facility desired to accomplish related to her visual deficits. The MDS nurse agreed there were no specifics in the care plan about the resident's vision. The care plan contained only a brief note to monitor for vision or hearing problems. This note was found under the activities of daily living problem area. Employee #15 confirmed there was a physician's orders [REDACTED]. This resident kept the appointment with the eye specialist on 07/02/14. The eye specialist wrote on a consultation sheet that the resident could have a special prescription for corrective lenses if the family desired. Employee #15 found nothing in the nurses' notes, after the appointment, that pertained to a family discussion about glasses. She did not know if the family was approached about the glasses. An interview was conducted with the Person in Charge, Employee #31, on 08/12/14 at 2:15 p.m. She said that licensed practical nurse, Employee #26, spoke with the eye doctor on 07/02/14 following the eye exam. The eye doctor allegedly said that he could prescribe glasses for the resident, but that it would be a waste of money. He would do so to appease the family, but it basically would be money wasted as it would not improve her eye sight. He reportedly said that it would work as well to go to a discount store and let her pick out some cheaper glasses that she might like. Employee #31 said this resident would rarely leave the facility. She said it would help if the resident would allow the staff to draw her curtains, but she generally did not want the curtains opened. She said she would see about getting her a separate light for her room. Upon relaying that the care plan had not been developed in the area of vision, she offered no further information. She acknowledged her understanding of the issue. | 2018-04-01 |
| 6242 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 323 | K | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the facility failed to provide an environment that was as free as possible from accident hazards over which it had control. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked and could be accessed by mobile residents. These situations created a potential for serious injury to residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. The former resulted in a determination of immediate jeopardy (IJ). A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. On 08/13/14 at 1:02 p.m., the State office directed to call an immediate jeopardy (IJ) related to the hot water temperatures of the men's and women's restrooms located in the corridor between the front and back halls. Employee #31, the Person in Charge (PIC), was notified immediately. On 08/13/14 at 1:50 p.m., Employee #31 provided a plan of correction. The correction was that the bathrooms had been locked, and were out of working order at that time, to safeguard residents until plumbing could be completed to permanently correct the problem. At 2:00 p.m. on 08/13/14, observation of the restrooms in question found only the restroom on the C hall beside the nurses' station, labeled women only, was locked. Upon inquiry, Employee #31 said she did not understand about the other restrooms. She said this would be taken care of immediately. On 08/13/14 at 2:12 p.m., the two (2) restrooms located in the corridor between the front and back halls were observed locked. Employee #31 said they would not allow access to these two (2) restrooms labeled men and women until the water temperature was regulated to a safe, functional level. Observations revealed the facility had implemented an acceptable plan of correction. The Immediate Jeopardy was abated on 08/13/14 at 2:12 p.m. At that time, the scope and severity was reduced from a K to an E. Findings include: a) Men and Women public restrooms between the front and back resident halls While completing the survey, it was noticed the water temperature of the sink in the female public restroom seemed hot to touch. This prompted further investigation of water temperatures in public and common use restrooms. An interview was conducted with Maintenance Employee #99 on 08/13/14 at 8:30 a.m. He said the facility does not maintain logs on the water temperatures. He said the water temperatures were checked monthly, and they strive to keep the water temperatures for the resident environment around 112 degrees, and not more than 117 degrees. He said the water in the two (2) public restrooms located in the corridor between the front and back resident halls, were on a separate line. The water lines for the two (2) restrooms were on the same line as the kitchen and the laundry. He said the water temperatures of those two (2) restrooms were much higher than the others, and were probably around 140 degrees Fahrenheit (F.). Review of the State Operations Manual revealed that the time required for a 3rd degree burn to occur at 140 degrees water temperature is five (5) seconds. On 08/13/14 beginning at 9:45 a.m., the water temperatures of resident common use restrooms and public restrooms, at or near the residents' living quarters, were assessed. The water temperatures at the sinks of the men's and women's public restrooms were checked by Maintenance Employee #97, using the facility's thermometer. These two (2) restrooms were located in the corridor between the front and back resident halls. These two (2) restrooms were unlocked, and could be accessed by anyone who desired to do so. It was not known at that time whether any residents used those two (2) restrooms. The temperature of the water from the sinks in both the women's and men's restrooms in this corridor was 160 degrees F. Review of the State Operations Manual revealed the time required for a 3rd degree burn to occur at 155 degrees water temperature was one (1) second. Licensed Practical Nurse (LPN) #38 was interviewed on 08/13/14 at 10:10 a.m. She said there were a total of four (4) ambulatory residents who resided on the C wing, and three (3) ambulatory residents who resided on the B wing. LPN #52 said there were three (3) residents on the A wing who were ambulatory. On 08/13/14 at 12:25 p.m., Nursing Assistant (NA) #16, and LPN #38 both said they had seen one (1) mobile resident on occasion use the women's public restroom located in the corridor between the front and back halls. They said Resident #17 from the C hall had been observed independently entering or exiting this women's public restroom after meals as she was walking from the back hall dining room to the front of the building. An interview was conducted with Resident #17 on 08/13/14 at 12:30 p.m. She said she occasionally used the women' public restroom located in the corridor between the front and back resident halls. She said she had never noticed the water from the sink being too cool in that restroom, but had noticed the water from the sink was too warm on occasion. Upon inquiry, she said she had never been burned by the water. The medical record of Resident #17 was reviewed on 08/13/14 at 12:40 p.m. According to the 04/23/14 care plan progress note, Resident #17 was understood, made her needs known, and was able to understand others. She was [AGE] years old with [DIAGNOSES REDACTED]. b) Two (2) resident common use restrooms on the C wing On 08/13/14 beginning at 9:45 a.m., the water temperatures of resident common use restrooms and public restrooms at or near the residents' living quarters were assessed. Employee #97 checked the water temperatures from the sinks in two (2) common use restrooms at the entrance to the C hall. These restrooms were located on the opposite wall from the B and C wing nurses' station. One (1) restroom door had a sign designating it was the residents' restroom. The second restroom was located directly behind the first, and had a sign on the door designating it was the women's restroom. The water temperature from the sinks of both of these common use restrooms was 120 degrees F. According to the State Operations Manual, the time required for a 3rd degree burn to occur in water temperatures of 120 degrees F is five (5) minutes. LPN #38 was interviewed on 08/13/14 at 10:10 a.m. She said there were a total of four (4) ambulatory residents who resided on the C wing, and three (3) ambulatory residents who resided on the B wing. LPN #52 said there were three (3) residents on the A wing who were ambulatory. On 08/13/14 at 12:25 p.m., LPN #26 said she had seen mobile residents from the C Hall, Residents #15 and #53, sometimes independently used the large common use toilet just off the C wing. At 1:02 p.m. on 08/13/14, LPN #38 was notified that the water temperatures of the sinks in the two (2) common use toilets on the C wing registered 120 degrees. She was informed that there were at least two (2) residents on the C hall who independently use those two (2) toilets. At 2:12 p.m. on 08/13/14, a surveyor observed that the two (2) common use restrooms on the C hall beside the nurses' station labeled resident's use and women only were locked. Employee #38 said the facility would not allow access to those two (2) restrooms located at the entrance to the C hall until the water temperature had been regulated to safe, functional levels. An interview was completed with the Person in Charge, Employee #31, on 08/13/14 at 2:00 p.m. The women's restroom, located in the corridor between the front hall and back hall residents' living quarters, was just outside her office. She said she would typically use that restroom. She said she had reported at least once that the water temperature at the sink had seemed too warm. She could not recall the date this occurred. She said it seemed like the water temperatures went up and down in the women's restroom. c) On 08/13/14 at 1:02 p.m., an immediate jeopardy (IJ) was called related to the hot water temperatures of the men's and women's restrooms located in the corridor between the front and back halls. Employee #31, the Person in Charge (PIC), was notified immediately. On 08/13/14 at 1:50 p.m., Employee #31 provided a plan of correction. The correction was that the bathrooms had been locked, and were out of working order at that time, to safeguard residents until plumbing could be completed to permanently correct the problem. At 2:00 p.m. on 08/13/14, observation of the restrooms in question found only the restroom on the C hall beside the nurses' station, labeled women only, was locked. Upon inquiry, Employee #31 said she did not understand about the other restrooms. She said this would be taken care of immediately. On 08/13/14 at 2:12 p.m., the two (2) restrooms located in the corridor between the front and back halls were observed locked. Employee #31 said they would not allow access to these two (2) restrooms labeled men and women until the water temperature was regulated to a safe, functional level. Observations revealed the facility had implemented an acceptable plan of correction. The Immediate Jeopardy was abated on 08/13/14 at 2:12 p.m. At that time, the scope and severity was reduced from a K to an E. | 2018-04-01 |
| 6243 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 329 | D | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the Center for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) guidelines for unnecessary medication, the facility failed to ensure one (1) of five (5) residents reviewed for unnecessary medications, during Stage 2 of the Quality Indicator Survey (QIS), was free from unnecessary medications. There was no evidence of a gradual dose reduction (GDR) for Resident #46 for a psychopharmacological medication (any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders) used for depression, anxiety and/or sleep induction. The resident received [MEDICATION NAME] (antidepressant) for over one (1) year without evidence of an attempted GDR. Resident identifier: #46. Facility census: 50. Findings include: a) Resident #46 A review of Resident #46's medical record, on 08/11/14 at 10:50 a.m., revealed [DIAGNOSES REDACTED]. The record revealed the resident had received [MEDICATION NAME] (antidepressant), 20 milligrams (mg) since 03/25/13. The [MEDICATION NAME] was ordered for depression with specific behaviors of withdrawn and tearfulness. A concurrent review of this resident's behavior sheets found no behaviors of being withdrawn and/or tearfulness for the past four (4) months. On 08/12/14 at 9:30 a.m., a confidential interview was conducted with a licensed practical nurse. This employee stated the resident had had no behaviors for months. On 08/12/14 at 10:18 a.m., a review of the monthly drug regimen review (DRR), from 03/25/13 through the current DRR, found no recommendations for a dosage reduction of the [MEDICATION NAME] from the consulting pharmacist. On 08/12/14 at 4:00 p.m., in an interview with the Person in Charge (PIC), she said she did not know if Resident #46 had had an attempted dose reduction of the ordered antidepressant. She stated it might be in the thinned records and she would attempt to find the information An interview with the PIC, on 08/13/14 at 8:18 a.m., revealed no evidence was found of an attempt to try a dosage reduction for the antidepressant ([MEDICATION NAME]) for this resident. She further stated there was no evidence the consultant pharmacist had considered the antidepressant for a dosage reduction. An interview was conducted with the consultant pharmacist, on 08/14/14 at 9:30 a.m The consultant pharmacist stated he did not recommend a dosage reduction for any resident receiving an antidepressant unless the dosage was above the maximum recommended dosage. If a resident was receiving an antidepressant above the recommend maximum dosage, he would make a recommendation to the physician for a dosage reduction. He further stated Resident #46 was not receiving a dosage above the maximum recommended dosage, so he had made no recommendations for a dosage reduction. In addition, he stated he did not agree with dosage reductions for antidepressants even thought he knew the regulation and had received a citation before. A review of CMS' SOM guidelines at 483.25 (l) Unnecessary Drugs: .when monitoring all psychopharmacological medications and sedative/hypnotics, the facility should review the continued need for them, at least quarterly (i.e., a 3 month period), and document the rationale for continuing the medication . .Often, however, the only way to know whether a medication is needed indefinitely and whether the dose remains appropriate is to try reducing the dose and to monitor the resident closely for improvement, stabilization, or decline . .Some medications (e.g., antidepressants, sedative/hypnotics, opioids) require more gradual tapering so as to minimize or prevent withdrawal symptoms or other adverse consequences . .Considerations Specific to Psychopharmacological Medications (Other Than Antipsychotics and Sedatives/Hypnotics). During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility should attempt to taper the medication during at least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a tapering should be attempted annually, unless clinically contraindicated . | 2018-04-01 |
| 6244 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 371 | F | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to ensure food was served in a safe and sanitary manner for seven (7) residents identified during a random opportunity for discovery. Observation found that nursing staff touched the residents' food with their bare hands, touched an unsanitary inanimate object, then immediately touched food contact surfaces. In addition, foods were not stored in a safe and sanitary manner. Food items in the freezer were found undated when opened and/or outdated. Opened foods in the freezer were also not securely re-closed to prevent potential contamination. These practices had the potential to affect all residents who received nourishment from the dietary kitchen. Resident identifiers: #46, #49, #56, #41, #20, #57, and #8. Facility census: 50. Findings include: a) During the noon meal on 08/05/14, between 11:35 a.m. and 12:00 p.m., the foods of several residents were touched by the bare hands of facility staff. - Employee #4 (nursing assistant) touched Resident #46's bread with her bare hands. - Employee #4 touched Resident #49's bread with her bare hands. - Employee #4 touched Resident #56's bread with her bare hands. - Employee #46 (nursing assistant) touched Resident #41's corn muffin with her bare hands. - After touching and positioning an unclean object (geri-chair of Resident #30), and without first sanitizing her hands, Employee #46 touched the spoon and bowl of beans of Resident #20. She then placed the bowl of beans and spoon into the hands of Resident #20 to begin feeding herself. - Resident #57. Employee #46 touched her corn muffin with her bare hands. - Resident #8. Employee #7 touched her bread with her bare hands. She also peeled the banana removed the banana from the peel with her bare hands and gave it to the resident. An interview was conducted with the certified dietary manager (CDM) and the registered dietitian on 08/06/14 at 12:00 p.m. They agreed staff were not allowed to have direct contact with residents' food. They also said staff must first sanitize their hands before coming into contact with the residents' eating utensils. The CDM said the dietary department could help with staff education in that area. An interview was conducted with registered nurse, Employee #31, on 08/12/14 at 8:00 a.m. She said staff were not allowed to touch the residents' food directly with their bare hands. She said they just went over that recently in an in-service. b) Dietary Freezer During observation of the freezer in the dietary department, on 08/05/14 at 4:00 p.m., the following food items were found undated when opened, outdated, and/or not securely re-closed to prevent potential contamination: - Two (2) opened bags of eggplant had no date to indicate when they were first opened. - A partially used bag of potato wedges was not closed. - An opened bag of tater tots had no date to indicate when it was first opened. - An opened bag of onion rings was left open and unsealed. - An opened bag of potato fries was not closed. - An opened bag of hash browns had no date to indicate when it was first opened. - An opened bag of Brussels sprouts had no date to indicate when it was first opened. - An opened bag of chicken patties had no date to indicate when it was first opened. - An opened bag of waffles had no date to indicate when it was first opened. - An opened bag of veggie wieners had no date to indicate when it was first opened. - A roast beef was not dated. - Two (2) bags of frozen taco meat were dated 07/03/14. During interview with the dietary manager at that time, she said staff knew better than to store food items in this manner. She said all foods must be dated when first opened. She said all opened foods must be properly sealed/closed. She said the facility allowed for freezer foods to be kept up to thirty (30) days before discarding. She said the facility would discard all of the above foods immediately. | 2018-04-01 |
| 6245 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 428 | D | 0 | 1 | EXXT11 | Based on medical record review, staff interview, and the State Operations Manual (SOM) Appendix PP, the consulting pharmacist failed to identify and report a medication irregularity for one (1) of five (5) residents reviewed for unnecessary medications in Stage II of the Quality Indicator Survey (QIS). The resident had not had a gradual dose reduction (GDR) for Celexa, a psychopharmacological medication (any mediation used for managing behavior, stabilizing mood, or treating psychiatric disorders), used by a resident for depression. The pharmacist failed to identify and report this irregularity. Resident identifier: #46. Facility census: 50. Findings include: a) Resident #46 Review of the medical record, on 08/11/14 at 10:50 a.m., found the resident was prescribed Celexa (antidepressant) 20 mg (milligrams) by mouth every day at 2000 (10:00 p.m.) due to depression. The beginning date for this medication was 03/25/13. On 08/12/14 at 10:18 a.m., a review of the monthly drug regimen review (DRR), from 03/25/13 through the most current DRR, found no recommendations for a dosage reduction for Celexa from the consulting pharmacist. An interview was conducted with the consultant pharmacist, on 08/14/14 at 9:30 a.m. The consultant pharmacist stated he did not recommend a dosage reduction for any resident receiving an antidepressant unless the dosage was above the maximum recommended dosage. If a resident was receiving an antidepressant above the recommend maximum dosage, he would make a recommendation to the physician for a dosage reduction. He further stated Resident #46 was not receiving a dosage above the maximum recommended dosage, so he had made no recommendations for a dosage reduction. In addition, he stated he did not agree with dosage reductions for antidepressants even though he knew the regulation and had received a citation before. A review of the Centers for Medicare and Medicaid Services SOM guidelines at 483.25 (l) Unnecessary Drugs: .when monitoring all psychopharmacological medications and sedative/hypnotics, the facility should review the continued need for them, at least quarterly (i.e., a 3 month period), and document the rationale for continuing the medication . .Often, however, the only way to know whether a medication is needed indefinitely and whether the dose remains appropriate is to try reducing the dose and to monitor the resident closely for improvement, stabilization, or decline . .Some medications (e.g., antidepressants, sedative/hypnotics, opioids) require more gradual tapering so as to minimize or prevent withdrawal symptoms or other adverse consequences . .Considerations Specific to Psychopharmacological Medications (Other Than Antipsychotics and Sedatives/Hypnotics). During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility should attempt to taper the medication during at least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a tapering should be attempted annually, unless clinically contraindicated . | 2018-04-01 |
| 6246 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 431 | E | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to provide safe and secure storage of medications. Controlled medications and other medications subject to abuse were not stored in a separately locked, permanently affixed compartment as required for medications listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976. The emergency medication supply box (labeled as narcotics) containing these medications, was observed locked and sitting on the counter top in the Hall B and C medication room. The box was not affixed to a secure location. This practice had the potential to affect more than a limited number of residents. Facility census 50. Findings Include: a) Observation of the B and C hall medication room, at 3:35 p.m., on 08/11/14, revealed a locked box marked narcotics. The box was not permanently affixed to a surface. Licensed Practical Nurse (LPN) #27 was present during the observation and said this was the emergency supply box of medications. The situation was reported to the Person in Charge (PIC). On 08/14/14 at 11:55 a.m., the emergency medication supply box was observed locked, but still was not permanently affixed. At that time, the PIC stated she had already ordered a box that could be permanently affixed. The contents of the emergency medication supply box were counted by the PIC. It contained the following: -- Hydrocodone with Tylenol 5/325 mg (milligrams) - two (2) tabs, -- Hydrocodone with Tylenol 10/325 mg - eight (8) tabs, -- Hydrocodone with Tylenol 10/500 mg - two (2) tabs, -- Ativan 0.5 mg - four (4) tabs, -- Phenergan 125 mg - seventeen (17) tabs, -- Oxycodone 5 mg - ten (10) tabs, -- Oxycodone with Tylenol 5/325 mg - nineteen (19) tabs, -- Valium 5 mg - three (3) tabs, -- Tylenol with Codeine 300/30 mg - three (3) tabs, -- Fentanyl Patch 25 mch, (micrograms) - three (3), -- Fentanyl Patch 75 mch - three (3), -- Morphine Sulfate 10 mg per 5 ml (millimeters), five (5) containers, -- Demerol 25 mg - nine (9) injections, -- Valium Injectable 10 mg/2 ml - ten (10), -- Morphine Sulfate 2 mg/1 ml - six (6) cartridges, -- Demerol 50 mg/1 ml - ten (10) cartridges, -- Morphine Sulfate 100 mg/4 ml IV injectable - one (1). | 2018-04-01 |
| 6247 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 441 | E | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to maintain an effective infection control program to prevent and control, to the extent possible, the onset and spread of infection within the facility. During a meal served in the fine dining room, employees touched residents' food items with bare hands. In addition, a nursing assistant (NA) touched an inanimate unclean object, then immediately served food to a resident without first completing hand sanitation. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #46, #49, #56, #41, #20, #57, #8. Facility census: 50. Findings include: a) During the noon meal on 08/05/14, between 11:35 a.m. and 12:00 p.m., the food of several residents was touched by the bare hands of facility staff: - Employee #4 (NA) touched Resident #46's bread with her bare hands. - Employee #4 touched Resident #49's bread with her bare hands. - Employee #4 touched Resident #56's bread with her bare hands. - Employee #46 (NA) touched Resident #41's corn muffin with her bare hands. - Employee #46, after touching and positioning an unclean object (geri-chair of Resident #30), and without first sanitizing her hands, touched the spoon and bowl of beans of Resident #20. She then placed the bowl of beans and spoon into the hands of Resident #20 to begin feeding herself. - Employee #46 touched Resident #57's corn muffin with her bare hands. - Employee #7 touched Resident #8's bread with her bare hands. She also peeled the banana removed the banana from the peel with her bare hands and gave it to the resident. An interview was conducted with the certified dietary manager (CDM) and the registered dietitian on 08/06/14 at 12:00 p.m. They agreed staff members are not allowed to have direct contact with residents' food. Also, staff must first sanitize their hands before coming into contact with food and eating utensils belonging to the residents. An interview was conducted with the Person in Charge, Employee #31, on 08/12/14 at 8:00 a.m. She said staff were not allowed to touch the residents' food directly with their bare hands. She said they just went over that recently in an in-service. | 2018-04-01 |
| 6248 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 490 | E | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Facility administration failed to ensure residents were as free as possible from accident hazards over which it had control. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. These situations created a potential for serious injury to more than an isolated number of residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. Census: 50. Findings include: a) Men and Women public restrooms between the front and back resident halls While completing the survey, it was noticed that the water temperature of the sink in the female public restroom seemed hot to touch. This prompted further investigation of water temperatures in public and common use restrooms. An interview was conducted with Maintenance Employee #99 on 08/13/14 at 8:30 a.m. He said the facility did not maintain logs on the water temperatures. He said the water temperatures were checked monthly, and they strive to keep the water temperatures for the resident environment around 112 degrees, and not more than 117 degrees. He said the water in the two (2) public restrooms located in the corridor between the front and back resident halls, were on a separate line. The water lines for these two (2) restrooms were on the same line as the kitchen and the laundry. Employee #99 said the water temperatures of these two (2) restrooms were much higher than the others, and were probably around 140 degrees Fahrenheit (F.). Review of the State Operations Manual revealed that the time required for a 3rd degree burn to occur at 140 degrees water temperature is five (5) seconds. On 08/13/14 beginning at 9:45 a.m., the water temperatures of resident common use restrooms and public restrooms, at or near the residents' living quarters, were assessed. The water temperatures at the sinks of the men's and women's public restrooms were checked by Maintenance Employee #97, using the facility's thermometer. These two (2) restrooms were located in the corridor between the front and back resident halls. These two (2) restrooms were unlocked, and could be accessed by anyone who desired to do so. It was not known at that time if any residents used these two (2) restrooms. The temperature of the water from the sinks in both the women's and men's restroom in this corridor was 160 degrees F. Review of the State Operations Manual revealed that the time required for a 3rd degree burn to occur at 155 degrees water temperature is one (1) second. Licensed Practical Nurse (LPN) #38 was interviewed on 08/13/14 at 10:10 a.m. She said there were a total of four (4) ambulatory residents who resided on the C wing, and three (3) ambulatory residents who resided on the B wing. LPN #52 said there were three (3) residents on the A wing who were ambulatory. On 08/13/14 at 12:25 p.m., Nursing Assistant (NA) #16, and LPN #38 both said they had seen one (1) mobile resident on occasion use the women's public restroom located in the corridor between the front and back halls. They said Resident #17 from the C hall had been observed independently entering or exiting this women's public restroom after meals as she was walking from the back hall dining room to the front of the building. An interview was conducted with Resident #17 on 08/13/14 at 12:30 p.m. She said she occasionally used the women' public restroom located in the corridor between the front and back resident halls. She said she had never noticed the water from the sink being too cool in that restroom, but had noticed the water from the sink was too warm on occasion. Upon inquiry, she said she had never been burned by the water. The medical record of Resident #17 was reviewed on 08/13/14 at 12:40 p.m. According to the 04/23/14 care plan progress note, Resident #17 was understood, made her needs known, and was able to understand others. She was [AGE] years old with [DIAGNOSES REDACTED]. b) Two (2) resident common use restrooms on the C wing On 08/13/14 beginning at 9:45 a.m., the water temperatures of resident common use restrooms and public restrooms at or near the residents' living quarters were assessed. Employee #97 checked the water temperatures from the sinks in two (2) common use restrooms at the entrance to the C hall. These restrooms were located on the opposite wall from the B and C wing nurses' station. One (1) restroom door had a sign designating it was the residents' restroom. The second restroom was located directly behind the first, and had a sign on the door designating it was the women's restroom. The water temperature from the sinks of both of these common use restrooms was 120 degrees F. According to the State Operations Manual, the time required for a 3rd degree burn to occur in water temperatures of 120 degrees F is five (5) minutes. LPN #38 was interviewed on 08/13/14 at 10:10 a.m. She said there were a total of four (4) ambulatory residents who resided on the C wing, and three (3) ambulatory residents who resided on the B wing. LPN #52 said there were three (3) residents on the A wing who were ambulatory. On 08/13/14 at 12:25 p.m., LPN #26 said she had seen mobile residents from the C Hall, Residents #15 and #53, sometimes independently use the large common use toilet just off the C wing. At 1:02 p.m. on 08/13/14, the Person in Charge (PIC) was notified that the water temperatures of the sinks in the two (2) common use toilets on the C wing registered 120 degrees. She was informed that there were at least two (2) residents on the C hall who independently used those two (2) toilets. Another interview was completed with the PIC on 08/13/14 at 2:00 p.m. The women's restroom, located in the corridor between the front hall and back hall residents' living quarters, was just outside her office. She said she would typically use that restroom. She said she had reported at least once that the water temperature at the sink had seemed too warm. She could not recall the date this occurred. She said it seemed like the water temperatures went up and down in the women's restroom. | 2018-04-01 |
| 6249 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 520 | E | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the quality and assessment (QA) committee failed to identify and implement a plan of action to correct a quality deficiency over which it had knowledge, or should have had knowledge. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. These situations created a potential for serious injury to more than an isolated number of residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. Facility census: 50 Findings include: a) Men and Women public restrooms between the front and back resident halls While completing the survey, it was noticed that the water temperature of the sink in the female public restroom seemed hot to touch. This prompted further investigation of water temperatures in public and common use restrooms. An interview was conducted with Maintenance Employee #99 on 08/13/14 at 8:30 a.m. He said the facility does not maintain logs on the water temperatures. He said the water temperatures are checked monthly, and they strive to keep the water temperatures for the resident environment around 112 degrees, and not more than 117 degrees. He said the water in these two (2) public restrooms located in the corridor between the front and back resident halls, are on a separate line. The water lines for these two (2) restrooms are on the same line as the kitchen and the laundry. Employee #99 said the water temperatures of these two (2) restrooms are much higher than the others, and are probably around 140 degrees Fahrenheit (F.). Review of the State Operations Manual revealed that the time required for a 3rd degree burn to occur at 140 degrees water temperature is five (5) seconds. On 08/13/14 beginning at 9:45 a.m., the water temperatures of resident common use restrooms and public restrooms, at or near the residents' living quarters, were assessed. The water temperatures at the sinks of the men's and women's public restrooms were checked by Maintenance Employee #97, using the facility's thermometer. These two (2) restrooms were located in the corridor between the front and back resident halls. These two (2) restrooms were unlocked, and could be accessed by anyone who desired to do so. It was not known at this time if any residents used these two (2) restrooms. The temperature of the water from the sinks in both the women's and men's restroom in this corridor was 160 degrees F. Review of the State Operations Manual revealed that the time required for a 3rd degree burn to occur at 155 degrees water temperature is one (1) second. Licensed Practical Nurse (LPN) #38 was interviewed on 08/13/14 at 10:10 a.m. She said there were a total of four (4) ambulatory residents who resided on the C wing, and three (3) ambulatory residents who resided on the B wing. LPN #52 said there were three (3) residents on the A wing who were ambulatory. On 08/13/14 at 12:25 p.m., Nursing Assistant (NA) #16, and LPN #38 both said they had seen one (1) mobile resident on occasion use the women's public restroom located in the corridor between the front and back halls. They said Resident #17 from the C hall had been observed independently entering or exiting this women's public restroom after meals as she was walking from the back hall dining room to the front of the building. An interview was conducted with Resident #17 on 08/13/14 at 12:30 p.m. She said she occasionally used the women' public restroom located in the corridor between the front and back resident halls. She said she had never noticed the water from the sink being too cool in that restroom, but had noticed the water from the sink was too warm on occasion. Upon inquiry, she said she had never been burned by the water. The medical record of Resident #17 was reviewed on 08/13/14 at 12:40 p.m. According to the 04/23/14 care plan progress note, Resident #17 is understood, makes her needs known, and understands others. She is [AGE] years old with [DIAGNOSES REDACTED]. b) Two (2) resident common use restrooms on the C wing On 08/13/14 beginning at 9:45 a.m., the water temperatures of resident common use restrooms and public restrooms at or near the residents' living quarters were assessed. Employee #97 checked the water temperatures from the sinks in two (2) common use restrooms at the entrance to the C hall. These restrooms were located on the opposite wall from the B and C wing nurses' station. One (1) restroom door had a sign designating it was the residents' restroom. The second restroom was located directly behind the first, and had a sign on the door designating it was the women's restroom. The water temperature from the sinks of both of these common use restrooms was 120 degrees F. According to the state operations manual, the time required for a 3rd degree burn to occur in water temperatures of 120 degrees F is five (5) minutes. LPN #38 was interviewed on 08/13/14 at 10:10 a.m. She said there were a total of four (4) ambulatory residents who resided on the C wing, and three (3) ambulatory residents who resided on the B wing. LPN #52 said there were three (3) residents on the A wing who were ambulatory. On 08/13/14 at 12:25 p.m., LPN #26 said she had seen mobile residents from the C Hall, Residents #15 and #53, sometimes independently use the large common use toilet just off the C wing. At 1:02 p.m. on 08/13/14, LPN, Employee #38, was notified that the water temperatures of the sinks in the two (2) common use toilets on the C wing registered 120 degrees. She was informed that there are at least two (2) residents on the C hall who independently use those two (2) toilets. An interview was completed with a member of the QA committee, the Person in Charge (PIC) Employee #31, on 08/13/14 at 2:00 p.m. The women's restroom, located in the corridor between the front hall and back hall residents' living quarters, was just outside her office. She said she would typically use that restroom. She said she had reported at least once that the water temperature at the sink had seemed too warm. She could not recall the date this occurred. She said it seemed like the water temperatures went up and down in the women's restroom. | 2018-04-01 |
| 6250 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2014-02-21 | 225 | D | 0 | 1 | CYPG11 | Based on record review, staff interview, and review of the Center for Medicare and Medicaid Services (CMS) S&C-05-09 letter, the facility failed to investigate and report an injury of unknown source to appropriate agencies. One (1) of one (1) resident reviewed for accidents had a fractured finger. The facility had not investigated the injury or reported the injury to the appropriate outside agencies. Resident identifier #8. Facility census: 11. Findings Include: a) Resident #8 On 02/18/14 at 10:27 a.m., an interview with Employee #9, Registered Nurse (RN), revealed Resident #8 sustained a fracture to the left little finger within the past 30 days. Resident #8's medical record, reviewed at 8:46 a.m. on 2/19/14, revealed the following nursing notes: -- 02/08/14 at 5:40 p.m., .Combative with staff during ADL (activities of daily living) care and bed bath. Scratched one of the CNA's in her right eye and caused her contact lens to come out -- 02/09/14 at 10:48 p.m., (typed as written): .Resident complained of her lt (left) hand hurting. Staff then called me into room to assess. Assessment of lt hand revealed bruising on outside of hand from wrist down to pinkie. Bruising wrapped around to both top and under side of hand. Resident refuses cold packs on hand. resident can not verify how or when she hurt her hand. -- 02/10/14 at 11:31 a.m., (typed as written): (L) (Left) hand 4th and 5th fingers swollen and very bruised. pt. (patient) c/o (complains of) pain in (L) hand. X-ray of (L) hand ordered A review of the X-ray report revealed Resident #8 had a non-displaced fracture involving the proximal phalanx of the little finger. On 02/19/14 at 9:04 a.m., Employee #8,the RN Nursing Manager of the Long Term Care Unit, reported she usually handled the reportable incidents if it happens during the day. She said if it happened in off hours, the nursing manager on call handled the reporting of the incident. Employee #8 stated they had a meeting about Resident #8 and the fracture she sustained to her left hand. She reported they discussed the injury and assumed it happened when Resident #8 was resisting care. She said the resident likely hit the side rail with her hand. She stated they were not sure this was what happened, but this was their best guess. Employee #8 stated she did not speak with the nurse aides, nor did she do an in- depth investigation into what could have happened to Resident #8's hand. She stated she did not speak to the nurse aide, who also received a scratch to the eye on 02/09/14. Employee #8 stated she never thought about talking to her about it. She confirmed she also had not talked to any other staff members to see if they recalled Resident #8 hitting her hand on the side rail during care. Employee #8 stated she did not report this to OHFLAC and APS as an injury of unknown source. She agreed that, due to the extent of the injury, the fact no one observed the injury, and the resident could not recall what happened that it did constitute an injury of unknown source. She stated the facility should have reported this as required. Employee #8 further agreed she should have spoken with nurse aides whom had worked with Resident #8 and she should have completed an in-depth investigation in attempts to determine what happened to Resident #8's finger. Review of the CMS letter S&C-05-09 dated 12/16/04 revealed the following: An injury should be classified as an 'injury of unknown source' when BOTH of the following conditions are met: 1. The source of the injury was not observed by any person OR the source of the injury could not be explained by the resident; AND, 2. The injury is suspicious because of the extent of the injury OR the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) OR the number of injuries observed at one particular point in time OR the incidence of injuries over time. | 2018-04-01 |
| 6251 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2014-02-21 | 272 | D | 0 | 1 | CYPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately assess one (1) of nine (9) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The facility did not complete the Care Area Assessment (CAA), a part of the Minimum Data Set (MDS), for Resident #18 in the areas of vision and [MEDICAL CONDITION] drug use. Resident identifier: #18. Facility census: 11. Findings include: a) Resident #18 Resident #18's medical record review, reviewed on 02/19/14 at 11:00 a.m., contained an admission minimum data set (MDS) with an assessment reference date (ARD) of 01/01/14. A review of the CAA summary worksheets for visual function and [MEDICAL CONDITION] drug use revealed the location of the documentation was the CAA worksheet dated 01/03/14. Review of the 01/03/14 CAA summary worksheets revealed no documentation on these summaries related to vision or [MEDICAL CONDITION] drug use. These summaries were blank. During an interview with Employee #9 (MDS Coordinator) at 12:30 p.m. on 02/19/14, she confirmed the CAA summaries for vision and [MEDICAL CONDITION] drug use had not been completed. She stated the facility had a new system and she had not realized the CAA summary portion of the assessment was not completed. | 2018-04-01 |
| 6252 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2014-02-21 | 323 | D | 0 | 1 | CYPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for accidents had an environment as free from accident hazards as possible. Resident #8 was known to hit her hand on the bed side rails while resisting care. The facility did not implement interventions to protect this resident from potentially injuring herself when resisting care. Resident Identifier: #8. Facility Census: 11. Findings Include: a) Resident #8 An interview with Employee #9, Registered Nurse (RN), at 10:27 a.m., on 02/18/14 revealed Resident #8 had a fracture to the left little finger. The RN stated we have no idea how she done it. Resident #8's medical record review, at 8:46 a.m. on 2/19/14, revealed the following nursing notes: -- 02/08/14 at 5:40 p.m., .Combative with staff during ADL (activities of daily living) care and bed bath. Scratched one of the CNA's in her right eye and caused her contact lens to come out -- 02/09/14 at 10:48 p.m., .Resident complained of her lt (left) hand hurting. Staff then called me into room to assess. Assessment of lt hand revealed bruising on outside of hand from wrist down to pinkie. Bruising wrapped around to both top and under side of hand. Resident refuses cold packs on hand. resident can not verify how or when she hurt her hand. -- 02/10/14 at 11:31 a.m., (typed as written) (L) (Left) hand 4th and 5th fingers swollen and very bruised. pt. (patient) c/o (complains of) pain in (L) hand. X-ray of (L) hand ordered -- 02/10/14 at 7:53 p.m., Late entry for 18:45 (7:45 p.m.) pt. (patient) assisted to bed by nursing staff. pt. yelling out. pt. hit staff member and hit (r) arm on bed rail. skin tear observed at old bruised site, cleaned with normal saline and skin smoothed over site and steri strips applied. The X-ray report review revealed Resident #8 had a non-displaced fracture involving the proximal phalanx of the little finger. During an interview with Employee #8, registered nurse (RN), nursing manager of the long-term care unit, at 9:04 a.m. on 02/19/14, she stated staff held a meeting about the fracture the resident sustained [REDACTED]. The staff discussed the injury and assumed it happened when the resident resisted care, by likely hitting the side rail with her hand. Employee #8 said they were not sure this is how the fracture occurred but they could not think of another cause for the injury. Employee #8 stated observations of Resident #8 revealed she hits the side rails with her hands. She said the resident hit the side rail on 02/10/14 and caused a skin tear to her right arm. Employee #8 confirmed they had not put any interventions in place to help prevent Resident #8 from receiving injuries when she hit the side rail. Employee #8 stated she thought about padding on the side rails, but the resident's call light and bed controls are on the side rails. An additional interview with Employee #8, at 10:45 a.m. on 02/20/14, revealed Resident #8 did not use the call light or bed controls contained on the bedside rail. The RN stated the resident was not able to use the call light or the controls. She stated Resident #8 usually hit the manual bell in her room. or just hit her bedside table to get staff's attention. She confirmed padding to the rail would not prevent her access to the bed controls or call light due to the fact she did not use either device. The RN did not give a specific reason why interventions were not in place to prevent this resident from injury from hitting the side rails with her hands. | 2018-04-01 |
| 6253 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2014-02-21 | 514 | D | 0 | 1 | CYPG11 | **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 and completeness of the clinical record for one (1) of twenty-four (24) residents. Resident #17 had an incorrect order for [MEDICATION NAME] (antidepressant). Resident identifier: #17. Facility census: 11.Findings include:a) Resident #17A review of the medication administration (MAR) record on 02/18/14 at 3:00 p.m., found an order for [REDACTED]. The director of nursing agreed, at 3:30 p.m. on 02/18/14, that the order for [MEDICATION NAME] was incorrect. She indicated the order for [MEDICATION NAME] should have read, [MEDICATION NAME] 10 mg tablets- give 1/2 tablet which equals 5 mg po daily. | 2018-04-01 |
| 6254 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 272 | D | 0 | 1 | 4OKO11 | Based on medical record review and staff interview, the facility failed to accurately assess one (1) of twenty-three (23) Stage 2 residents. A comprehensive assessment was coded inaccurately for pressure ulcers. Resident identifier: Resident #66. Facility census: 88. Findings include: a) Resident #66 This resident's medical record was reviewed on 01/22/14 at 12:16 p.m., and revealed the resident's history of pressure ulcers since admission. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/18/13, was coded 1 under Item M0210, which indicates the presence of one or more unhealed pressure ulcers at Stage 1 or higher. Item M0900, was coded 1, which indicated pressure ulcers were present on the prior assessment. The annual MDS assessment, with an ARD of 12/18/13, was coded 0, under Item M0900, which indicated pressure ulcers were not present on the prior assessment. An interview conducted with Employee #102 (Registered Nurse Assessment Coordinator), on 01/22/14 at 4:20 p.m., confirmed the MDS assessment was coded incorrectly. | 2018-04-01 |
| 6255 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 278 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the health professional who completed Item M0900, healed pressure ulcers, of the comprehensive assessment for one (1) of twenty-three (23) Stage 2 sample residents certified the accuracy of this portion; however, Item M0900 did not accurately reflect the resident's pressure ulcer status. Resident identifier: #66. Facility Census: 88. Findings include: a) Resident #66 Review of the medical record on 01/22/14 at 12:16 p.m., revealed Resident #66 had a history of [REDACTED]. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/18/13, was coded as 1 for Item M0210, which indicated the presence of one or more unhealed pressure ulcers at Stage 1 or higher. The annual MDS assessment, with an ARD of 12/18/13, was coded 0, for Item M0900, which indicated pressure ulcers were not present on the prior assessment. An interview conducted with Employee #102 (Registered Nurse Assessment Coordinator), on 01/22/14 at 4:20 p.m. confirmed the MDS assessment had been coded inaccurately. | 2018-04-01 |
| 6256 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 279 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans which described the care and services necessary to meet the medical, mental, and/or psychosocial needs for four (4) of twenty-three (23) residents in Stage 2 of the Quality Indicator Survey. The care plans lacked nonpharmacologic interventions for conditions being treated with [MEDICAL CONDITION] medications, in an effort to reduce or eliminate the use of the medications. Resident identifiers: #91, #104, #151, and #87. Facility census: 88. Findings include: a) Resident #91 Medical record review revealed Resident #91 was prescribed [MEDICATION NAME] for a [MEDICAL CONDITION],[MEDICATION NAME], and [MEDICATION NAME] for anxiety. Review of the medical records revealed the care plan did not identify specific nonpharmacologic interventions to address the resident's [MEDICAL CONDITIONS], and anxiety. On 01/23/14 at 10:43 a.m., registered nurse, Employee #102, acknowledged there were no nonpharmacologic interventions in the care plan for this resident. b) Resident #104 Medical record review revealed Resident #104 was currently [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] for anxiety, and [MEDICATION NAME], and [MEDICATION NAME] for a [MEDICAL CONDITION]. Review of the medical records revealed the care plan did not include nonpharmacologic interventions for the resident's [MEDICAL CONDITION], anxiety, or [MEDICAL CONDITION] in an effort to reduce or eliminate the use of the pharmaceuticals. On 01/23/14 at 10:43 a.m., register nurse, Employee #102, acknowledged there were no nonpharmacologic interventions in the resident's care plan to address the conditions for which the resident was receiving medications. c) Resident #151 Medical record review revealed Resident #151 was prescribed [MEDICATION NAME] related to a [MEDICAL CONDITION] to [MEDICAL CONDITION]. Review of the medical records revealed the resident's care plan did not identify specific nonpharmacologic interventions to address the resident's [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 01/23/14 at 10:43 a.m., registered nurse, Employee #102 acknowledged there were no nonpharmacologic interventions identified in the resident's care plan. d) Resident #87 On 01/23/14 at 4:12 p.m., a review of Resident #87's care plan revealed an intervention Attempt interventions before my behaviors begin. No evidence could be found as to what interventions were to be attempted. In an interview on 01/23/14 at 3:43 p.m., the director of nursing stated there was no reason to discuss this as the care plan for this resident was not complete with interventions to attempt before behaviors began. | 2018-04-01 |
| 6257 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 280 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to update a care plan to reflect the resident's current medical condition. This was found for one (1) of twenty-three (23) Stage 2 sample residents. Resident #99's current care plan contained goals and interventions for insulin dependent diabetes, a [DIAGNOSES REDACTED]. Resident identifier: #99. Facility census: 88. Findings include: a) Resident #99 Review of the resident's medical record, on 01/22/14 at 8:30 a.m., revealed Resident #99's current medical [DIAGNOSES REDACTED]. The resident's current care plan, dated 12/16/13, and updated on 12/31/13, listed insulin dependent diabetes as a current diagnosis. Goals and interventions had been established and remained a part of the care plan. Further review of the Medication Administration Record [REDACTED]. An interview was conducted with Employee #102 (registered nurse assessment coordinator) on 01/22/14 at 11:18 a.m. She reviewed the resident's current Medication Administration Record [REDACTED]. She acknowledged the resident was no longer receiving insulin and agreed the care plan needed to be revised to indicate this issue was resolved. | 2018-04-01 |
| 6258 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 282 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and observation the facility failed to provide care as indicated on the care plan for six (6) of twenty-three (23) Stage 2 quality indicator survey, sample residents. Residents #91, #104, #151, #147, and #87's care plans included monitoring for side effects of [MEDICAL CONDITION] medications. This monitoring did not occur. Resident #71's care plan included using a positioning wedge and Prevalon boots which were either not used or used inappropriately. Resident identifiers: #91, #104, #151, #147, #71, and #87. Facility census: 88. Findings include: a) Resident #91 On 01/23/14, review of the care plan, with an initiated date of 01/10/14, revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications. The resident was prescribed an anti-depressant. An intervention was, Monitor for side effects and report to physician. Review of medical records revealed no evidence monitoring for side effects of [MEDICAL CONDITION] medications was being done. b) Resident #104 Resident #104's care plan, with an initiated date of 07/12/13, was reviewed on 01/23/14. The care plan revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications for for anxiety and depression. Both medications had interventions to: Monitor for side effects and report to physician. Review of medical records revealed no evidence that monitoring for side effects of [MEDICAL CONDITION] medications was being done. c) Resident #151 Review of the 01/23/14 care plan for Resident #151 revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications. The resident's current Medication Administration Record [REDACTED]. Care plan interventions for both of these medications included Monitor for side effects and report to physician. Review of medical records revealed no evidence monitoring for side effects of [MEDICAL CONDITION] medications was being done. d) On 01/23/14 at 2:00 p.m., an interview with a registered nurse, Employee #102 was conducted. Employee #102 stated there was no nursing documentation related to monitoring of the side effects of the prescribed [MEDICAL CONDITION] medications as listed in the care plan interventions for Residents #91, #104, and #151. e) Resident #147 During a Stage 1 interview, on 01/20/14 at 4:09 p.m., a white bandage was observed on the fifth (5th) finger of Resident #147's right hand. He said he had scratched it on the wheelchair rim. The resident said there was a sharp area on the rim he used to propel himself. He indicated he first noticed it at breakfast. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff was to monitor the resident for skin tears and bruising for increased bleeding. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. No indication of skin impairment was evident in the medical record. Further review of the medical record, on 01/22/14 at 1:01 p.m revealed no order for treatment. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. The determination of capacity, completed on 01/08/14, indicated the resident had capacity. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because it may have been related to the rust lifted. He added, I bled pretty bad. An interview with the director of nursing (DON) and executive director (ED) on 01/22/14 at 2:06 p.m. revealed they were unaware of an injury. The DON said the policy was to complete a DQI (incident report) and they would follow up with it. The DON reviewed the medical record and DQI reports. She confirmed she was unable to provide evidence the resident's skin tear had been assessed and monitored. f) Resident #71 Medical record review on 01/23/14 at 3:30 p.m., revealed Resident #71 required extensive assistance with his activities of daily living (ADL) due to immobility and reduced range of motion. Positioning aids were required, to maintain his current level of physical function. The care plan, created on 07/08/10, and most recently revised on 11/14/13, identified the resident's goal to maintain his current level of physical function. Interventions included a positioning wedge placed under his knees and between his legs with his ankles floated on a pillow roll. In addition, the care plan stated Prevalon boots were to be worn on both feet when up in a chair and not to be utilized with the positioning wedge. Random observations of the resident, on 01/21/14 through 01/23/14, found the resident up in his reclining wheelchair without the Prevalon boots on his feet. During an interview with Employee #34 (nursing assistant) on 01/24/14 at 9:30 a.m., she pulled back the resident's blanket and explained the positioning wedge that was under Resident #71's legs. In addition, she explained the Prevalon boots that were on the resident's feet while the positioning wedge was in place. Employee #5 (licensed practical nurse) reviewed Resident #71's care plan during an interview on 01/24/14 at 10:00 a.m. She stated the resident did not need both the Prevalon boots and the wedge when he was in bed. She confirmed Resident #71 was positioned in his bed with both the Prevalon boots and the positioning wedge. g) Resident #87 A review of Resident #87's care plan, conducted on 01/23/14 at 4:12 p.m., revealed specific drug side effects to be monitored for [MEDICATION NAME] (antipsychotic medication). The interventions, with an initiated date of 03/21/13, stated Monitor for side effects and report to physician. Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (extrapyramidal symptoms), weight gain, [MEDICAL CONDITION], postural [MEDICAL CONDITION], sweating, loss of appetite, [MEDICAL CONDITION]. A concurrent review of the medial record revealed no monitoring of the side effects were recorded on the Behavior Monthly Flowsheet or the Medication Administration Record [REDACTED]. In an interview with the director of nursing (DON), on 01/23/14 at 4:46 p.m., she stated there was no additional evidence the side effects had been monitored. She further stated there was a problem with monitoring side effects of medications for residents on antipsychotic medications and the system was broken. . | 2018-04-01 |
| 6259 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 309 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and policy review, the facility failed to provide the care and services to attain, or maintain the highest practicable physical,mental,and psychosocial well-being for one (1) of three (3) residents reviewed for skin integrity. A resident with impaired skin integrity was not assessed and monitored. Resident identifier: #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on the wheelchair rim. He related it had bled pretty bad, and staff put a bandage on it. The resident said the rim he used to propel himself had a sharp area on it causing the scratch. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff would monitor the resident for skin tears, and bruising for increased bleeding related to [MEDICATION NAME] therapy. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. Further review of the medical record, on 01/22/14 at 1:01 p.m. revealed no orders for treatments to the resident's skin. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. The determination of capacity, completed on 01/08/14, indicated the resident had capacity. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident. He informed her he had cut his finger on the silver part of the wheelchair because It may have been related to the rust lifted. He added, I bled pretty bad. He showed her rust areas along the rim and the taped area. He indicated staff used tape to cover the area where he cut his finger. Employee #6 told the resident she would have someone look at the wheelchair, and placed the chair by his bed. He informed the nurse he was concerned someone else might get a bigger cut than he did. An interview with the occupational therapist (OT), on 01/22/14 at 1:17 p.m., revealed she was not aware of a problem with the wheelchair. The OT confirmed therapy provided the resident with the wheelchair. She observed the tape and said it was not present when she provided Resident #147 with the wheelchair. Employee #73 (LPN) was interviewed on 01/22/14 at 2:07 p.m. She revealed vital signs were obtained, the physician and family were notified, a DQI (incident report) was completed, and an SBAR (change in condition note) was completed for a change in condition or with an incident/accident. She said staff would Monitor and continue charting for a certain number of days. The LPN also said staff would note the response to care in the medical record. An interview with director of nursing (DON) and executive director (ED), on 01/22/14 at 2:06 p.m.,revealed they were unaware of an injury or problem with the wheelchair. The DON confirmed the policy was to complete a DQI and the facility would follow up with it. The director of nursing reviewed the progress notes and DQI reports and said no information was available. She also reviewed the medical record and confirmed no information was available related to treatment of [REDACTED]. Review of the clinical health status/change of condition guideline, on 01/22/14 at 2:46 p.m. revealed the process for identification of change of condition included gathering of objective data and documenting assessment findings, resident response, physician and family notification. Communication both written and verbal, and was to include a concise statement of the problem, pertinent and brief information related to the situation, subjective and objective assessment of condition, nurse's assessment of the situation, recommendation or action needed to correct the problem. Another interview with the DON on 01/24/14 at 9:50 a.m., confirmed the resident's condition was not assessed, monitored, treated, and evaluated in accordance with standards of practice and the facility policy. | 2018-04-01 |
| 6260 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 323 | D | 0 | 1 | 4OKO11 | Based on medical record review, staff interview, resident interview, and observation, the facility failed to ensure the residents environment was as free from accident hazards as was possible for one (1) of three (3) residents reviewed with impaired skin integrity. A resident alleged an injury from a defective wheelchair. The chair had rusted causing sharp areas on the wheel utilized for self-propelling. Resident identifier: Resident #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on a sharp area on the wheelchair rim he used to propel himself. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because It may have been related to the rust lifted. He added, I bled pretty bad. He showed her rust areas along the rim. He also showed her a taped area, which he said staff used to cover the area where he cut his finger. She told the resident she would have someone look at it, and placed the chair back at the lower side of his bed. He informed the nurse he was concerned someone else may get a bigger cut than he did. An interview with the occupational therapist (OT), on 01/22/14 at 1:17 p.m., indicated she was not aware of a problem with the wheelchair. The OT said therapy provided the chair to the resident. She observed the tape and said it was not there when the chair was given to the resident. She looked at the chair and acknowledged rust along the silver area of the chair. Incident and accident reports were reviewed on 01/22/14 at 1:46 p.m. They revealed no evidence a report had been completed to identify or evaluate hazards or risks associated with the wheelchair. An interview with the therapy program director, a physical therapist (PT), on 01/24/14 at 9:30 a.m., revealed the wheelchair was removed from use. She said it was going to be sent to the shed. The PT indicated the maintenance department had not looked at the wheelchair yet, but she did not think it was going to be able to be fixed, and the part would have to be replaced. During an interview with the director of nursing (DON) and executive director (ED) on 01/23/14 at 9:30 a.m., they confirmed a DQI (incident report) report had not been completed, which did not allow for further analysis of risks associated with use of the wheelchair. There was no evidence the wheelchair had been periodically inspected to ensure it was in good condition. | 2018-04-01 |
| 6261 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 328 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, resident comment, and staff interviews, the facility failed to ensure a resident with a gastrostomy tube received proper treatment and care. A nurse administered a resident's medication through his gastrostomy tube using ice water. Resident identifier: #92. Facility census: 88. Findings include: a) Resident #92 During an observation of medication administration, on 01/22/14 at 3:31 p.m., Employee #73, a licensed practical nurse (LPN) poured the medication [MEDICATION NAME] sulfate 325 milligrams (mg), crushed it, and placed it in a cup. She poured water from the pitcher into the cup to mix the medication. She poured an additional cup of water from the same pitcher. The LPN carried both cups into the room and set them on the bedside stand. She administered the medication via the resident's enteral tube, utilizing the water she had poured from the pitcher. When she first flushed the tube with the water, the resident startled, and his eyes widened. Upon inquiry, the resident said he was okay. An interview with Employee #73 (LPN), on 01/22/14 at 4:45 p.m. confirmed she used ice water to administer the medication and flush the feeding tube. She said she should have used tap water. (Putting the ice water through the tube did not allow warming of the water as would happen if the resident had swallowed the water and it had warmed while passing through the esophagus before reaching the stomach.) Review of the facility's medication administration competency check list for enteral tubes, on 01/22/14 at 4:00 p.m., revealed medications were to be administered with warm water. Review of the pharmacy enteral tube medication administration, on 01/23/14 at 4:30 p.m., also indicated warm water was to be utilized. During an interview with the director of nursing (DON) on 01/22/14 at 4:50 p.m., she confirmed the standard of practice was not followed; and the nurse incorrectly administered the medication to Resident #92. | 2018-04-01 |
| 6262 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 329 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review the facility failed to ensure three (3) of five (5) Stage 2 quality insurance survey sample residents reviewed for unnecessary medications, were free of unnecessary medications. The facility failed to identify nonpharmacological interventions for residents prescribed [MEDICAL CONDITION] medications, failed to monitor for adverse effects of medications and failed to identify the wrong reason for medication administration on a physician order. Resident identifiers: #104, #149, #87, and #22. Facility census: 88. Findings Include: a) Resident #104 Review of medical records, on 01/23/14, revealed Resident #104 received [MEDICATION NAME] and [MEDICATION NAME] for depression,[MEDICATION NAME], and [MEDICATION NAME] for anxiety. Continued review, of Resident #104's medical records, failed to find evidence the facility attempted to implement non-pharmacologic interventions or explore any underlying causes of distressed behavior before administering a psychopharmacologic medication. Employee #102 provided the Behavior Monthly Flow Sheets for the last three (3) months. These flow sheets were completed by the licensed nursing staff each shift. These documents listed the medications and the reason the medication was prescribed. The Behavior Monthly Flow Sheet did not list non-pharmacological interventions specific to Resident #104 and revealed no evidence of monitoring the resident for side effects of the medications. This was confirmed by Employee #102 on 01/23/14 at 2:00 p.m. b) Resident #149 Review of the medical record, on 01/23/14 at 8:23 a.m., revealed Resident #149 was admitted to the facility on [DATE] for rehabilitation services. His admission orders [REDACTED]. The medication orders included an order for [REDACTED]. The Medication Administration Record [REDACTED]. Resident #149 received the [MEDICATION NAME] daily between 01/17/14 and 01/23/14. [MEDICATION NAME] is given for [MEDICAL CONDITION] reflux and depression may be a side effect of the medication for some individuals. During an interview with Employee #23 (director of nursing services) on 01/23/14 at 1:20 p.m., she agreed the [MEDICATION NAME] order contained the wrong indication for use and stated they would correct the order. c) Resident #87 A review of Resident #87's care plan, on 01/23/14 at 4:12 p.m., revealed specific drug side effects to be monitored for [MEDICATION NAME] (antipsychotic medication). The interventions, with an initiated date of 03/21/13, included, Monitor for side effects and report to physician. Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (extrapyramidal symptoms), weight gain, [MEDICAL CONDITION], postural [MEDICAL CONDITION], sweating, loss of appetite, [MEDICAL CONDITION]. A concurrent review of the medial record found no evidence of monitoring of the side effects on the Behavior Monthly Flowsheet or the Medication Administration Record [REDACTED]. In an interview with the director of nursing (DON), on 01/23/14 at 4:46 p.m., she stated there was no additional evidence the side effects had been monitored. She further stated there was a problem with monitoring side effects of residents on antipsychotic medications and the system was broken. d) Resident #22 On 01/22/2014 9:28 a.m., a review of Resident 22's care plan was conducted. The care plan, with an initiated date of 09/24/13, included, Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, [MEDICAL CONDITIONS] muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain. In addition, an intervention, with an initiated date of 06/11/13, was Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (extrapyramidal symptoms), weight gain, [MEDICAL CONDITION], postural [MEDICAL CONDITION], sweating, loss of appetite, [MEDICAL CONDITION]. A review of the medical record found no monitoring of the side effects on the Behavior Monthly Flowsheet or the MAR for the months of November and December 2013, and January 2014. In an interview with the director of nursing (DON), on 01/23/14 at 4:46 p.m., she stated there was no additional evidence the side effects had been monitored. She further stated there was a problem with monitoring side effects of residents on antipsychotic medications and the system was broken. | 2018-04-01 |
| 6263 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 332 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure the medication error rate was below five percent. Observation of medication administration pass identifed two (2) errors in the thirty (30) opportunities observed. This resulted in an error rate of 6%. A resident's blood pressure and pulse were not obtained for a resident as required by the physician's orders [REDACTED]. Resident identifiers: #106 and #144. Facility census: 88. Findings include: a) Resident #106 Observation of medication administration was completed with Employee #11, a licensed practical nurse (LPN), on 01/22/14 at 4:40 p.m. Resident #106 was not in his room. The LPN went down the hallway to find the resident. The nurse returned to the cart and the resident propelled himself up the hallway to the medication cart. The LPN poured the medications and administered them to the resident. Vital signs (VS) were not taken at that time. Review of the physician's orders [REDACTED]. Review of vital signs through 01/23/14 noted the last blood pressure taken was dated 01/21/14. Review of the Medication Administration Record [REDACTED]. Additionally, the progress notes were reviewed and revealed no evidence vital signs were obtained prior to administering the medication. An interview with the director of nursing (DON),on 01/23/14 at 1:00 p.m., confirmed no evidence was available to indicate vital signs were obtained prior to administering the medication. Review of the administration procedures for all medications, on 01/23/14 at 4:30 p.m., revealed prior to removing the medication package/container from the cart/drawer, the nurse was to check the Medication Administration Record [REDACTED]. b) Resident #144 Observation of medication administration with Employee #85, a licensed practical nurse (LPN), on 01/23/14 at 8:41 a.m., revealed [MEDICATION NAME] 100 mg (one capsule) was administered orally to Resident #144. Review of the medical record, on 01/23/14 at 11:00 a.m., revealed an order for [REDACTED]. Another interview with Employee #85, on 01/23/14 at about 11:30 a.m., confirmed she had only administered one tablet. She reviewed the physician's orders [REDACTED]. | 2018-04-01 |
| 6264 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 428 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, the pharmacist failed to identify a medication irregularity during her monthly medication review and report it the attending physician and the director of nursing. This was found for one (1) of five (5) Stage 2 sampled residents. Resident #149's admission orders [REDACTED]. Resident identifier: #149. Facility census: 88. Findings include a) Resident #149 Review of the medical record, on 01/23/14 at 8:23 a.m., revealed Resident #149 was admitted to the facility on [DATE] for rehabilitation services. His admission orders [REDACTED]. The medication orders included an order for [REDACTED]. The order stated (typed as written): Prilosec capsule delayed release 20 mg (milligrams) (Omeprazole) Give 1 capsule by mouth one time a day related to depressive disorder not elsewhere classified (311). (Prilosec is given for gastrointestinal disorders.) The medication administration record (MAR) also stated (typed as written): Prilosec capsule delayed release 20 mg (Omeprazole) Give 1 capsule by mouth one time a day related to depressive disorder not elsewhere clasiffied (311). Resident #149 received the Prilosec daily between 01/17/14 and 01/23/14. The clinical pharmacist medication regimen review summary indicated the pharmacist (Employee #104) reviewed the resident's medications on 01/17/14 and documented she had no recommendations. The facility policy titled, Medication Monitoring Medication Regimen Review, section 9.1, included in section E The consultant pharmacist's evaluation includes, but is not limited to reviewing and/or evaluating the following: 1) A written diagnosis, indication, or documented objective findings support each medication order. Part 3 of section E states: Indications for use and therapeutic goals are consistent with current medical literature and clinical guidelines. During an interview on 01/23/14 at 1:20 p.m., Employee #23 (director of nursing) reviewed Resident #149's MAR and active orders and confirmed the order for Prilosec was written incorrectly and this had not been noted by the pharmacist. | 2018-04-01 |
| 6265 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 431 | E | 0 | 1 | 4OKO11 | Based on observation, staff interview, review of manufacturer's instructions, and policy review, the facility failed to ensure medications were stored appropriately or according to pharmacy recommendations. A resident's medication was stored with stock medications, a multi dose vial was not labeled with the date opened, tuberculin serum was not refrigerated, and intravenous fluids with and without medications added were expired. This had the potential to affect more than a limited number of residents. Facility census: 88. Findings include: a) Medication Storage 1) North hall During an observation of the north hall medication room, with Employee #68, a licensed practical nurse (LPN), on 01/21/14 at 2:00 p.m., heparin lock flush belonging to a resident, was stored with stock medications. The nurse said, It shouldn't be here. Review of the south hall medication room with Employee #5 (LPN), on 01/21/14 at 2:15 p.m., found expired intravenous (IV) solutions. The IV solutions were: -- Lactated Ringers 1000 milliliters (ml), expired June 2013 -- Lactated Ringers 1000 ml, expired July 2013 -- 0.45 Normal Saline (NS) 1000 ml, expired June 2013 -- 0.9% (percent) Sodium Chloride (NaCl) attached to piperacillin/tazopactum (an antibacterial agent) 50 ml x 5 doses, expired December 2013 -- 0.9% NaCl 50 ml with meropenem (an antibiotic) expired October 2013 0.9% NaCl 50 ml with cefepime (an antibiotic) x 2 doses expired December 2013 0.9% NaCl 50 ml with Rocephin (an antibiotic) expired December 2013 0.9% NaCl 50 ml with Rocephin expired July 2013 0.9% NaCl 50 ml with Rocephin expired August 2013 Additionally, the pharmacy label was removed from one bag of 0.9% NaCl 50 ml with meropenum. Employee #5, (LPN) said the pharmacy representative reviewed the medications in September. She said the pharmacy came in Labor Day. The LPN also related the medications and intravenous fluids were to be checked monthly. 2) South hall Review of the south hall medication cart 2, with Employee #11 (LPN) on 01/22/14 at 3:00 p.m., found an open multi-dose vial of tuberculin serum in the cart. It was not labeled with the date opened or an expiration date, and had no indication of when it was received from the pharmacy. Employee #11 said the vial was to be dated when opened, and added, I wouldn't use it. According to manufacturer's recommendations, this should be discarded 30 days after the vial is entered. The manufacturer's instructions for storage and handling also include PPD solution must be kept refrigerated at 36 degrees to 46 degrees Fahrenheit. b) An interview with the director of nursing (DON), on 01/22/14 at 3:15 p.m., revealed the pharmacy was to check the medication/IV solutions monthly. Upon inquiry, she said the pharmacist completed an inspection and made recommendations monthly. On 01/23/14 at 3:50 p.m., medication safety systems assessments, completed by the pharmacist, were reviewed for the months of November and December 2013, and January 2014. The issues identified by the pharmacist included, but were not limited to: medication stored without a label, multi dose vial not dated, and expired medications. Review of the medication storage guidelines, on 01/22/14 at 2:52 p.m., revealed all medications dispensed by the pharmacy were stored in the container with the pharmacy label; medications labeled for individual residents were stored separately from floor stock medications when not in the medication cart; out dated medications were to be secured and immediately removed from inventory; medications requiring refrigeration were kept in a refrigerator; and once opened multiple dose vials required an expiration date shorter than the manufacturers' expiration date. The guidelines indicated, once the seal was broken, a date opened sticker would be placed on the vial, with a new expiration date of 30 days, unless otherwise directed. Additionally, review of the medication destruction policy revealed unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed. During an interview with the executive director (ED), assistant director of nursing (ADON), and director of nursing (DON), on 01/24/14 at 10:45 a.m., they acknowledged a systems failure related to medication storage. They confirmed no plan was in place to correct the ongoing issues related to expired medication, dating and labeling medications, and medications without pharmacy labels. | 2018-04-01 |
| 6266 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 441 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and review of infection control organism reports, the facility failed to maintain an infection control program to provide a safe, sanitary environment, and to help prevent the development and transmission of disease and infection. The infection control program did not conduct surveillance and investigate identified organisms in the facility in order to attempt to identify possible transmission of organisms from one resident to another. This practice had the potential to affect more than a limited number of residents residing in the facility. In addition, staff failed to adhere to posted contact precautions by not wearing personal protective equipment (PPE) during an observed dressing change. This was true for one (1) resident of the one (1) dressing change observed. Resident identifier: #99. Facility census: 88. Findings include: a) Infection Control Program On 01/23/14 at 9:00 a.m. a review of the infection control program and reports was conducted. During this review of the available reports, for August, September and October 2013, revealed a Query Summary Report from the local area hospital conducting the facility's culture and sensitivity laboratory reports. August reports revealed the following organisms: -- [MEDICATION NAME] faecium (2) -- Proteus mirabilis September reports revealed the following organisms: -- [DIAGNOSES REDACTED] Pneumoniae -- Morganella morganii -- Proteus mirabilis -- Escherichia coli October reports revealed the following organisms: -- [MEDICATION NAME] faecium -- Escherichia coli (3 residents) -- Pseudomonas aeruginosa -- Providencia stuartii An additional report, titled Golden Living Center Infection Control Committee Meeting Minutes for August, September and October 2013, was reviewed at this same time. This report did not identify any of the above organisms present in the facility during these months. On 01/23/14 at 9:55 a.m., an interview with the infection control nurse/nurse educator. A review of the Query Summary Report and the Golden Living Center Infection Control Committee Meeting Minutes was conducted. The infection control nurse/nurse educator stated she did not realize the organisms were reported on the Query Summary Report and these organisms were not identified on the report. She further agreed she did not track these organisms for a possible transmission from one resident to another. In addition, during this interview, when asked about the Plan noted on the infection control minutes, the infection control nurse/nurse educator stated she had provided inservices regarding handwashing and infection control measures during med (medication) pass during orientation, but was not able to provide an evidence of monitoring of handling of linen and other potentially infectious materials by staff and treatment observations. An interview with the administrator (NHA) was conducted. The NHA was informed of the review of the infection control reports and minutes and he stated we dropped the ball on this. He further stated he recognized this issue was brought to the Quality Assurance and Assessment (QAA) committee and nothing was happening with the reports. b) Resident #99 Medical record review on 01/22/14 at 08:30 a.m., revealed Resident #99 was placed in contact isolation on 01/13/14 for a [DIAGNOSES REDACTED]. The physician order, written on 01/13/14, was Contact isolation every shift for ESBL. Resident #99's room was identified as an isolation area with an isolation cart outside the doorway and a contact isolation sign hung on the door. Random observations on 01/21/14 and 01/22/14 verified the staff did not gown or glove upon entering the room. During wound care observation on 01/22/14 at 1:25 p.m., Employee #21 (licensed practical nurse) was observed performing a dressing change with clean gloves and no gown. Her scrub suit and the facility key ring were in direct contact with the resident's bed linen as the nurse reached across the bed. During a follow up interview, on 01/22/14 at 2:15 p.m., LPN #21 acknowledged Resident #99 was on contact isolation and she should have had a gown on when entering his room and performing his dressing change. Registered nurse #12 (director of clinical education and infection control) provided the facility's infection control policy for contact isolation during an interview on 01/22/14 at 1:57 p.m. She verified Resident #99 was on contact isolation for ESBL and all staff members should wear gowns when entering the room and caring for the resident as their policy states. The facility policy titled Isolation - Categories of Transmission - Based Precautions, included in part d of the section titled Gown (1) Wear a disposable gown upon entering the Contact Precautions room or cubicle. (2) . do not allow clothing to contact potentially contaminated environmental surfaces. | 2018-04-01 |
| 6267 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 514 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the clinical health status/change of condition guideline, and staff interview, the facility failed to ensure the accuracy of the medical record for one (1) of three (3) residents reviewed for impaired skin integrity. The medical record did not reflect the status of an accident with injury. Resident identifier: #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on the wheelchair rim. The resident said the rim he used to propel himself had a sharp area on it. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff was to monitor the resident for skin tears and bruising for increased bleeding. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. No indication of skin impairment was evident. Further review of the medical record, on 01/22/14 at 1:01 p.m. revealed no order for treatment. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because it may have been related to the rust lifted. He added, I bled pretty bad. An interview with director of nursing (DON and executive director (ED), on 01/22/14 at 2:06 p.m.,revealed they were unaware of an injury or problem with the wheelchair. The DON said the policy was to complete a DQI (incident report) and the facility would follow up with the problem. The DON reviewed the progress notes and DQI reports and said no information was available. She also reviewed the medical record and confirmed it was incomplete. An interview with Employee #73 (LPN) on 01/22/14 at 2:07 p.m., revealed vital signs are obtained, the physician and family are notified, a DQI is completed, and an SBAR (change in condition note) is completed. She said staff was to monitor and continue charting for a certain number of days. The LPN said staff would note the response to care in the medical record. Review of the clinical health status/change of condition guideline, on 01/22/14 at 2:46 p.m., revealed the process for identification of change of condition included gathering of objective data and documenting assessment findings, resident response, physician and family notification. Communication, both written and verbal, and was to include a concise statement of the problem, pertinent and brief information related to the situation, subjective and objective assessment of condition, nurse's assessment of the situation, recommendation or action needed to correct the problem. An interview with the DON on 01/24/14 at 9:50 a.m., confirmed the clinical record was not maintained in accordance with accepted professional standards. The record did not provide an accurate picture of the resident's status, including assessment and treatment of [REDACTED]. | 2018-04-01 |
| 6268 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 520 | F | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the Quality Assessment and Assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The facility failed to address deficiencies identified during pharmacy audits which included improper storage and labeling of medications, and expired medications. The facility failed to identify, monitor and track infections and there were no audits in place to evaluate isolation precaution practices. This had the potential to affect all residents. Facility census: 88. Findings include: a) The medication safety system assessments were reviewed for the months of November 2013, December 2013, and January 2014 on 01/23/14 at 3:50 p.m. Deficiencies identified by the pharmacist included: medication stored without a label, a multidose vial not dated, and expired medications. An interview was conducted with Employee #37 (executive director), Employee #149 (assistant director of nursing), and Employee # 23 (director of nursing) on 01/24/14 at 10:45 a.m. They reported there was no plan of correction in place to correct the ongoing issues related to the improper storage and labeling of medications or the presence of expired medications. On 01/24/14 at 11:00 a.m., Employee #37 (executive director and QAA Contact Person) reported the QAA committee had stopped performing audits six (6) months ago after completing a mock survey. The QAA committee reviewed resident care areas including activities of daily living, pressure ulcers, infections, incontinence, catheter care, pain, psychiatric medication use, behaviors, falls, elopement, [MEDICATION NAME] and grievances monthly. The committee was aware of the pharmacy audit results for November 2013, December 2013, and January 2014, which included improper storage and labeling of medications and the presence of expired medications within the current resident stock supplies, however a plan of action was not created to correct the deficiencies. b) The infection control program did not conduct surveillance and investigate identified organisms in the facility in order to attempt to identify an outbreak. A review of the available reports, August, September and October 2013, revealed a Query Summary Report from the local area hospital conducting the facilities cultures and sensitivity laboratory reports. August reports revealed the following organisms: [MEDICATION NAME] faecium (2), and Proteus mirabilis. September reports revealed the following organisms: [DIAGNOSES REDACTED] Pneumoniae, Morganella morganii, Proteus mirabilis, and Escherichia coli. September reports revealed the following organisms: [MEDICATION NAME] faecium, Escherichia coli (3 residents), Pseudomonas aeruginosa, and Providencia stuartii. An additional report, titled Golden Living Center Infection Control Committee Meeting Minutes for August, September and October 2013, was also reviewed. This report did not identify any of the above organisms present in the facility during these months. On 01/23/14 at 9:55 a.m., Employee #12 (infection control nurse/nurse educator) stated she did not realize the organisms were reported on the Query Summary Report and these organisms were not identified on the Golden Living report. She acknowledged she did not track these organisms for possible indications of transmission to other residents. In addition, when asked about the Plan noted on the infection control minutes, the infection control nurse/nurse educator was not able to provide any evidence of monitoring infections or staff compliance with isolation practices. On 01/24/14 at 11:00 a.m., Employee #37 (executive director and QAA Contact Person) reported the QAA committee had stopped performing audits six (6) months ago after completing a mock survey. The QAA committee reviewed resident care areas including activities of daily living, pressure ulcers, infections, incontinence, catheter care, pain, psychiatric medication use, behaviors, falls, elopement, [MEDICATION NAME] and grievances monthly. He acknowledged the infection reports and minutes were reviewed at the QAA committee meeting but no action plans were discussed or put into place. | 2018-04-01 |
| 6269 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2015-04-16 | 225 | D | 1 | 0 | AU7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to report potential neglect to the appropriate state agencies for one (1) of ten (10) residents reviewed. Staff failed to secure the lift pad when transferring Resident #11 with a mechanical lift, which resulted in a fall. Resident identifier: Resident #11. Facility census: 112. Findings include: a) Resident #11 During a medical record review, on 04/15/15 at 11:15 a.m., a progress note, dated 03/02/15, indicated Resident #11 required a total lift with transfers and activities of daily living (ADLs). The current care plan, reviewed on 04/15/15 at 11:41 a.m., indicated the resident required assistance with transfers and locomotion due to disease/compromising functional ability. It specified the use of a mechanical lift for transfers. The care plan also indicated Resident #11 was at risk for additional falls. The care plan falls history noted the resident had a change in condition, dated 03/09/15, related to a recent fall. A change of condition note, dated 02/18/15 at 7:25 p.m. indicated an accident/incident/fall in the past 72 hours. The note indicated the resident experienced back pain, which started after the fall. Further review of the medical record, on 04/15/14 at 12:45 p.m., revealed a progress note, dated 02/28/15 at 7:25 p.m. which indicated the resident was experiencing back pain and was sent to the emergency room for evaluation. Another progress note, at 7:57 p.m., indicated the resident sustained [REDACTED]. A progress note at 10:59 p.m. indicated the resident was transferred to the emergency room for a computerized tomography (CT) scan. The risk management report, supplied upon request on 04/15/15 at 1:45 p.m., indicated on 02/18/15, two (2) nursing assistants attempted to transfer Resident #11 from the shower chair to the bed, utilizing the mechanical lift. According to the report, the lift straps came off lift and resident fell to floor. The report indicated the nursing assistant partially caught the resident's upper body to keep her head from hitting the floor. The resident complained of back pain, and was sent to the emergency room for evaluation. The lift-transfer-repositioning evaluation completed on 02/12/15, reviewed on 04/15/15 at 3:45 p.m., indicated Resident #11 required a total lift for transfers. The facility's reportable allegations, reviewed initially on 04/14/15 at 3:30 p.m., and again on 04/15/15 at 1:00 p.m., provided no indication the fall was reported to the appropriate state agencies. The abuse/neglect reporting requirements for West Virginia (WV) nursing homes was provided by the facility. The reporting requirements were reviewed with the administrator on 04/14/15 at 4:00 p.m. The form indicated 42 CFR 488.301 required the facility to report to the Office of Health Facility and Licensure (OHFLAC), adult protective services (APS), and the ombudsman, of a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness, regardless of whether the perpetrator actually meant or intended to cause harm. An interview with the director of nursing, on 04/15/15 at 3:15 p.m., confirmed the facility did not report the fall from the lift to the appropriate state agencies. | 2018-04-01 |
| 6270 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2015-04-16 | 280 | D | 1 | 0 | AU7811 | Based on medical record review, observation, and staff interview, the facility failed to revise a care plan for one (1) of ten (10) sample residents. Resident #25's care plan was not revised to include the required use of a gait belt. Resident identifier: #25. Facility census: 112. Findings include: a) Resident #25 Review of risk management reports, on 04/14/15 at 2:30 p.m., revealed Resident #25 fell while being transferred from the shower chair to the bed, on 01/20/15 at 6:30 a.m. The report indicated the nursing assistant lowered the resident to the floor, and the resident was assisted back to bed via a lift. The assessment noted a large abrasion running vertically down the resident's back. The report did not note whether or not a gait belt was utilized. On 04/16/15 at 8:30 a.m., review of the resident's most recent lift-transfer-repositioning evaluation, dated 11/29/14 (before the fall), revealed the resident required the use of a gait belt for transfers. The most recent evaluation, completed on 03/01/15, also indicated the resident required the use of a gait belt with transfers. The care plan, reviewed on 04/16/15 at 8:46 a.m., provided no indication Resident #25's transfer status required the use of a gait belt. An interview with the director of nursing (DON) confirmed the comprehensive care plan did not indicate the resident required a gait belt for transfers. The DON also confirmed the Kardex (care plan utilized by nursing assistants) did not indicate the resident required the use of a gait belt for transfers. | 2018-04-01 |
| 6271 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2015-04-16 | 315 | D | 1 | 0 | AU7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to ensure one (1) of ten (10) residents reviewed received treatment and services to maintain or restore as much bladder function as possible. The facility failed to fully implement a planned voiding diary to assess the resident's bladder continence/incontinence; therefore, appropriate interventions were not planned and implemented to maintain or restore as much bladder function as possible. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the electronic medical record (EMR), on 04/14/15 at 2:49 p.m., revealed Resident #114 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Her brief interview for mental status (BIMS) score was 14, which indicated minimal cognitive impairment. A score of 15 is the highest available score. The minimum data set (MDS), with an assessment reference date (ARD) of 01/30/15, reviewed on 04/14/15 at 2:51 p.m., revealed urinary incontinence triggered under section V, with a decision to care plan the problem. The care plan, reviewed on 04/14/15 at 3:17 p.m., indicated Resident #114 required extensive/ total assist with activities of daily living (ADL) care, which included toileting. The care plan indicated the resident was cognitively impaired and unable to participate in a toileting program, even though the BIMS score was 14. Urinary incontinence nursing interventions, dated 02/13/15, noted functional incontinence with use of absorbent products. A nursing assessment, dated 01/30/15, indicated Resident #114 believed she was able to improve in some areas of activities of daily living (ADLs.) Another nursing assessment, dated 02/18/15, noted the resident was frequently incontinent of bowel - not on a toileting program and frequently incontinent of urine - not on a toileting program. A third nursing assessment, dated 03/17/15, indicated Resident #114 was always incontinent of bowel with no toileting program and occasionally incontinent of urine with no toileting program. Review of the continence management policy, on 04/16/15 at 9:00 a.m., revealed a three (3) day voiding diary would be completed, and a plan of care developed, based on information from assessments and the diary. The three (3) day voiding diary, completed 01/29/15 through 01/31/15, was reviewed on 04/14/15 at 3:45 p.m. It had not been completed every two (2) hours as required: -- On 01/29/15, there were no entries for 7-9 p.m., 9-11 p.m., 11 p.m.-1 a.m., 1-3 a.m., 3-5 a.m. and 5-7 a.m. -- On 01/30/15, there were no entries for 11 a.m.-1 p.m., 1-3 p.m., 3-5 p.m., 5-7 p.m., 7-9 p.m., 9-11 p.m., 11 p.m.-1 a.m., 1-3 a.m., 3-5 a.m., and 5-7 a.m. -- On 01/31/15, there were no entries for 3-5 p.m., 5-7 p.m., 7-9 p.m., 9-11 p.m., 11 p.m.-1 a.m., 1-3 a.m., 3-5 a.m., and 5-7 a.m. Additionally, only one (1) of twelve (12) entries indicated the resident was toileted. Five (5) of five (5) entries indicated the resident was dry, but not toileted to promote continence. A care plan intervention, dated 03/05/15, indicated a three (3) day voiding diary would be completed to evaluate for patterns of incontinence at appropriate intervals. Review of the medical record provided no evidence of this assessment. The care plan indicated a prompted toileting program was not initiated until 03/17/15, although the resident was identified as requiring assistance on 03/05/15. Review of the activity of daily living (ADL) sheets revealed Resident #114 was incontinent for fifty eight (58) of fifty nine (59) entries in February 2015. The March 2015 ADL sheets indicated the resident was incontinent 03/01/15-03/09/15 on night shift and on 03/01/15-03/05/15. During an interview with the director of nursing, on 04/15/15 at 10:00 a.m., she confirmed the voiding diary was not implemented as required by their policy. She also acknowledged the facility had not assessed and provided appropriate treatment and services to maintain as much normal urinary function as possible and/or to improve the resident's urinary functioning. | 2018-04-01 |
| 6272 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2015-04-16 | 323 | D | 1 | 0 | AU7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed to provide an environment that was as free as possible from accident hazards, over which the facility had control, for two (2) of ten (10) residents reviewed. Resident #11 fell from a mechanical lift related to a failure to properly secure the lift pad. In addition, a lift -transfer-evaluation indicated Resident #25 required the use of a gait belt for transfers. This was not identified in the resident's care plan or identified by any other means for staff awareness. Resident identifiers: #11 and #25. Facility census: 112. Findings include: a) Resident #11 During a medical record review, on 04/15/15 at 11:15 a.m., a progress note, dated 03/02/15, indicated Resident #11 required a total lift with transfers and activities of daily living (ADLs). The current care plan, reviewed on 04/15/15 at 11:41 a.m., indicated the resident required assistance with transfers and locomotion due to disease/compromising functional ability. It specified the use of a mechanical lift for transfers. The care plan also indicated Resident #11 was at risk for additional falls. The care plan falls history noted the resident had a change in condition, dated 03/09/15, related to a recent fall. A change of condition note, dated 02/18/15 at 7:25 p.m. indicated an accident/incident/fall in the past 72 hours. The note indicated the resident experienced back pain which started after the fall. Further review of the medical record, on 04/15/14 at 12:45 p.m., revealed a progress note, dated 02/28/15 at 7:25 p.m. which indicated the resident was experiencing back pain and was sent to the emergency room for evaluation. Another progress note, at 7:57 p.m., indicated the resident sustained [REDACTED]. A progress note at 10:59 p.m. indicated the resident was transferred to the emergency room for a computerized tomography (CT) scan. The risk management report, supplied upon request on 04/15/15 at 1:45 p.m., indicated on 02/18/15, two (2) nursing assistants attempted to transfer Resident #11 from the shower chair to the bed, utilizing the mechanical lift. According to the report, the lift straps came off lift and resident fell to floor. The report noted the straps were not securely fastened and the lift pad separated from the lift, resulting in a fall. The resident complained of back pain, and was sent to the emergency room for evaluation. b) Resident #25 Risk management incident and accident reports, reviewed on 04/14/15 at 11:30 a.m., revealed Resident #25 sustained a fall while being transferred from the shower chair to the bed, on 01/20/15 at 6:30 a.m. The report indicated the nursing assistant lowered the resident to the floor and the resident was assisted back to bed via a lift. The assessment noted a large abrasion running vertically down the resident's back. The report did not note whether or not a gait belt was utilized. On 04/16/15 at 8:30 a.m., review of the resident's most recent lift-transfer-repositioning evaluation, dated 11/29/14 (before the fall), revealed the resident required the use of a gait belt for transfers. Review of the resident's current care plan, on 04/16/15 at 9:00 a.m., revealed no directives to use a gait belt during transfers. An interview with Employee #86, a nursing assistant (NA), on 04/16/15 at 9:30 a.m., revealed residents who required the use of a gait belt had the initials GB on the doorpost of their rooms beside his/her name. Observation of Resident #25's doorpost revealed the letters were not present. The NA related the resident did not require the use of a gait belt. On 04/16/15 at 10:00 a.m., the director of nursing (DON) confirmed the resident's door did not have the letters GB to alert staff that Resident #25 required the use of a gait belt with transfers. She said the letters were ordered last Friday, which would have been 04/10/15. The DON confirmed a system had not been put in place to ensure the resident's safety, after the facility became aware the letters which indicated the resident required a gait belt were missing. The DON also confirmed neither the comprehensive care plan nor the Kardex (care plan utilized by nursing assistants) indicated the resident required the use of a gait belt for transfers | 2018-04-01 |
| 6273 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2015-04-23 | 241 | D | 1 | 0 | 4O0D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview the facility failed to ensure staff interactions with residents and their family members were conducted in a respectful, professional manner that respected their dignity and accommodated their needs and expectations. An inappropriate, confrontational encounter related to medication administration took place between a nurse and a family member of Resident #114. This was found for one (1) of seven (7) residents reviewed. Facility census: 112. Findings include: a) The medical record review, on 04/21/15 at 11:49 a.m., revealed Resident #114 was admitted to the facility on [DATE] and discharged home on[DATE]. b) During an interview with a family member of Resident #114, on 04/21/15 at 11:12 a.m., the family member related that on the evening of 02/12/15 a nurse was in the resident's room to give her 9:00 p.m. medication at 12:00 midnight. The family member said the nurse awoke the resident and spoke to her in a loud voice that the family member felt was inappropriate. A second nurse intervened, sending the assigned nurse out of the room and administered the medication. The next morning, the family member spoke to someone who they thought was in some type of management position and asked them who they should speak with to report a concern with one of the nurses. This person said she would have someone contact them, but no one ever did. c) Review of schedules for February 2015, on 04/22/15 at 10:30 a.m., identified licensed staff working the 7:00 p.m. to 7:00 a.m. shift on 02/12/15. Two (2) nurses were interviewed on the evening of 04/22/15. Nurse #7, interviewed on 4/22/15 at 7:18 p.m., was asked if they recalled any incident involving Resident #114 on the night of 02/12/15. Nurse #7 said they recalled hearing a heated discussion in Resident #114's room around midnight. Nurse #7 went to the room to intervene. The concern appeared to involve administration of Resident #114's medication, [MEDICATION NAME] (appetite stimulant). Nurse #7 told Nurse #8 (assigned nurse) to leave the room, and Nurse #7 administered Resident #114's medication. Nurse #7 said they took the action to defuse the situation. Nurse #7 could not speak to anything that may have occurred before they arrived at the door to Resident #114's room. Nurse aide #7 was unable to recall if she said anything to anyone about the incident. Licensed practical nurse (LPN) #8 was interviewed on 04/22/15 at 7:30 p.m. The LPN was asked if they recalled a confrontation with the family of Resident #114 on the night of 02/12/15. LPN #9 said they could not recall anything specific to that night, but they had some conflicts with the family related to their practice of staying in the room all night while Resident #114 was in the facility. The LPN could not recall any conflict over medication administration while Resident #114 was in the facility. | 2018-04-01 |
| 6274 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 253 | D | 0 | 1 | FSTL11 | Based on observation and staff interview, the facility failed to ensure the physical environment was in good repair. The adjoining shower room, shared by residents occupying rooms 33 and 35 on B-hall, had missing floor tiles. A black substance was observed between the floor tiles, on the wooden base board and the lower walls of the shower stall. Observation of room 26-B found the back wall, facing the outside of the facility, was in need of repair. Three (3) of the thirty-four (34) rooms observed during Stage 1 of the Quality Indicator Survey were affected. Room numbers of the affected rooms: #33-B, #35-B, and #26-B. Facility census: 66. Findings include: a) Observation of the facility during Stage 1 of the Quality Indicator Survey, on 11/04/13, revealed the following rooms had environmental concerns: 1) Rooms 33-B and 35-B On 11/04/13 at 2:25 p.m., observation of the bathroom shared by residents in rooms 33-B and 35-B found the bathroom was equipped with a private shower stall. Further observation of the shower stall, at 2:25 p.m. on 11/04/13, found a black substance was present on the tiled area at the entrance of the shower stall. This substance could be scraped off with a fingernail. The black substance was also found along the wooden baseboards in the shower stall and covered an area approximately two (2) feet upward from the baseboard on the back wall and the right wall of the shower stall. Four (4) floor tiles were missing along the edge of the floor beside the right wall, leaving an uneven area on the shower floor. Observation of the shower stall by two (2) surveyors and the maintenance supervisor, Employee #5, was made at 2:00 p.m. on 11/07/13. Employee #5 stated he had the materials to fix the shower, but he had not had time to complete the repairs. Employee #9 (a nursing assistant) and Employee #69 (a register nurse) were interviewed at 2:45 p.m. on 11/07/13. Both employees verified the two (2) residents in room #35 and one resident in room #33 were bathed in the adjoining shower room. 2) Room 26-B Observation of room 26-B, at 2:05 p.m. on 11/04/13, revealed an area on the outer wall of the room, located to the left of the heater and above the base board, had crumbling plaster and could be pushed in with a slight touch of a hand. At 2:05 p.m. on 11/07/13, the outer wall of room 26-B was observed by Employee #5 and the same two (2) surveyors. A surveyor pointed out the wall with crumbling plaster and demonstrated the wall could be pushed in with the touch of a hand. Employee #5 stated he was unaware of any problems in this room. | 2018-04-01 |
| 6275 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 272 | E | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, observations, and staff interview, the facility failed to ensure resident assessments were accurate and complete. Four (4) of twenty-four (24) residents on the sample had inaccurate assessments. Dental assessments for Resident #144 and #102 did not reflect the residents had broken teeth. The assessment for Resident #52 did not identify that a toileting program had been implemented. The assessment for Resident #45 did not accurately reflect the assistance the resident required for toileting. Resident identifiers: #144, #102, #52, and #45. Facility census: 66. Findings include: a) Resident #144 An observation of Resident #144's mouth on 11/04/13 at 3:43 p.m., revealed she had broken and loose teeth. The resident stated her teeth were broken and loose on the top and the bottom. On 11/06/13 at 10:16 a.m., Resident #144 said she had some loose and broken teeth. An observation of the resident's mouth revealed she did have broken teeth. The initial nursing assessment, dated 10/21/13, indicated the resident did have broken natural teeth. However, the expanded nursing assessment, dated 10/28/13 did not capture the resident had broken natural teeth. The minimum data set (MDS) admission assessment, assessment reference date (ARD) 10/28/13, did not capture the resident's broken natural teeth in Section L (oral/dental status). At 10:40 a.m. on 11/06/13, Employee #62 (MDS/care plan registered nurse) and Employee #4 (MDS/care plan registered nurse) both said the MDS and assessment did not capture the resident's dental status. They indicated two (2) nursing assessments were completed prior to the admission MDS. The second nursing admission assessment (nursing assessment expanded) did not capture the resident's broken natural teeth. This prevented the MDS from capturing it in Section L (oral/dental status). b) Resident #102 During an interview on 11/04/13 at 4:21 p.m., Resident #102 said she had a broken tooth on top. Observation revealed the resident did have a broken upper tooth. The expanded nursing assessment, dated 01/21/13, indicated the resident had a broken or loosely fitting full or partial denture. The expanded nursing assessment, dated 04/26/13, did not indicate the resident had any dental issues. The expanded nursing assessment dated [DATE] indicated the resident had broken or loosely fitting full or partial denture. The expanded nursing assessment of 10/13/13 did not indicate the resident had any dental issues. Resident #102's quarterly MDS, with an ARD of 04/14/13, Section L (oral dental status) indicated the resident did not have broken or loosely fitting full or partial denture. The significant change MDS, ARD of 04/24/13, Section L indicated the resident did not have obvious or likely cavity or broken natural teeth. The quarterly review MDS, ARD 07/23/13, indicated the resident had a broken or loosely fitting full or partial denture. The quarterly MDS, ARD 10/13/13, indicated the resident did not have obvious or likely cavity or broken teeth. On 11/06/13 at 2:10 p.m., Employee #4 verified the MDS and nursing assessments were incorrect in relation to the resident's dental status. c) Resident #52 At 11:30 a.m. on 11/07/13, medical record review revealed Resident #52 had a physician's orders [REDACTED]. Documentation in the resident's medical record indicated Resident #52 had a prompted voiding program for bladder and bowel in September 2013. The documentation identified the facility offered the resident toileting in the morning and upon rising and before and after meals and at bedtime. The resident's quarterly minimum data set (MDS) admission assessment, assessment reference date (ARD) 10/08/13, Section H (urinary toileting program) did not indicate the resident had been on a urinary toileting program since urinary incontinence was noted in the facility. d) Resident #45. A review of the minimum data set (MDS) with an assessment reference date (ARD) of 10/15/13, on 11/06/13 at 2:00 p.m., found Item G0110, toilet use for self-performance was coded as a three (3), indicating extensive assistance of staff was required.A review of the activity daily living record (ADLR), on 11/06/13 at 2:05 p.m., revealed toilet use for self-performance for the ARD of 10/15/13 was supervision and that the resident required limited assistance one (1) time. Employee #62, clinical care reimbursement coordinator, (CRC), reviewed the ADLR with the ARD of 10/15/13. She confirmed Resident #45's MDS was inaccurate and that this resident should have been coded as limited assistance. She stated a correction request would be necessary due to the inaccuracy. Review of the MDS, on 11/06/13 at 4:45 p.m., revealed a correction request dated 11/06/13, had been completed. Under Section G0110, toilet use was updated to reveal Resident #45 correctly coded as a two (2) indicating limited assistance for self-performance. . | 2018-04-01 |
| 6276 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 278 | E | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure four (4) of twenty- four (24) residents had assessments that accurately reflected their status in the areas of toileting and oral/dental status. Resident identifiers: #144, #102, #52, and #45. Facility census: 66. Findings include: a) Resident #144 An observation of Resident #144's mouth on 11/04/13 at 3:43 p.m., revealed she had broken and loose teeth. The resident stated her teeth were broken and loose on the top and the bottom. The initial nursing assessment, dated 10/21/13, indicated the resident did have broken natural teeth. However, the expanded nursing assessment, dated 10/28/13 did not capture the resident had broken natural teeth. The minimum data set (MDS) admission assessment, assessment reference date (ARD) 10/28/13, did not capture the resident's broken natural teeth in Section L (oral/dental status). At 10:40 a.m. on 11/06/13, Employee #62 (MDS/care plan registered nurse) and Employee #4 (MDS/care plan registered nurse) both said the MDS and assessment did not capture the resident's dental status. They indicated two (2) nursing assessments were completed prior to the admission MDS. The second nursing admission assessment (nursing assessment expanded) did not capture the resident's broken natural teeth. This prevented the MDS from capturing it in Section L (oral/dental status). b) Resident #102 During an interview on 11/04/13 at 4:21 p.m., Resident #102 said she had a broken tooth on top. Observation revealed the resident did have a broken top tooth. The expanded nursing assessment, dated 01/21/13, indicated the resident had a broken or loosely fitting full or partial denture. The expanded nursing assessment, dated 04/26/13, did not indicate the resident had any dental issues. The expanded nursing assessment dated [DATE] indicated the resident had broken or loosely fitting full or partial denture. The expanded nursing assessment of 10/13/13 did not indicate the resident had any dental issues. Resident #102's quarterly MDS, with an ARD of 04/14/13, Section L (oral dental status) indicated the resident did not have broken or loosely fitting full or partial denture. The significant change MDS, ARD of 04/24/13, Section L indicated the resident did not have obvious or likely cavity or broken natural teeth. The quarterly review MDS, ARD 07/23/13, indicated the resident had a broken or loosely fitting full or partial denture. The quarterly MDS, ARD 10/13/13, indicated the resident did not have obvious or likely cavity or broken teeth. On 11/06/13 at 2:10 p.m., Employee #4 verified the MDS and nursing assessments were incorrect in relation to the resident's dental status. c) Resident #52 At 11:30 a.m. on 11/07/13, the medical record review revealed Resident #52 had a physician's orders [REDACTED]. Documentation in the resident's medical record indictated Resident #52 had a prompted voiding program for bladder and bowel in September 2013. The documentation identified the facility offered the resident toileting in the morning and upon rising and before and after meals and at bedtime. The resident's quarterly minimum data set (MDS) admission assessment, assessment reference date (ARD) 10/08/13, Section H (urinary toileting program) did not indicate the resident had been on a urinary toileting program since urinary incontinence was noted in the facility. d) Resident #45 A review of the minimum data set (MDS) on 11/06/13 at 2:00 p.m. for Resident #45, revealed the assessment reference date (ARD) of 10/15/13, under section G0110, toilet use for self-performance coded as a three (3), indicating extensive assistance required.A review of the activity daily living record (ADLR) on 11/06/13 at 2:05 p.m., revealed toilet use for self-performance for the ARD of 10/15/13 is supervision and that the resident required limited assistance one time. Employee #62, clinical care reimbursement coordinator, (CRC), reviewed the ADLR with the ARD of 10/15/13. She confirmed Resident #45's MDS was inaccurate and that this resident should have been coded as limited assistance. She stated a correction request would be necessary due to the inaccuracy. Review of the MDS on 11/06/13 at 4:45 p.m., revealed a correction request date of 11/06/13. Under Section G0110, toilet use was updated to reveal Resident #45 correctly coded as a two (2) indicating limited assistance for self-performance. | 2018-04-01 |
| 6277 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 279 | D | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to ensure the resident's comprehensive care plan included all of the specific interventions, detailed in the physician's orders [REDACTED]. This was true for one (1) of twenty-four (24) residents' care plans reviewed during Stage 2 of the Quality Indicator Survey. Resident identifier: #10. Facility census: 66. Findings include: a) Resident #10 Observation of the resident during Stage 1 of the Quality Indicator Survey, at 2:20 p.m. on 11/04/13, found the resident's right hand was contracted. On 11/06/13, further review of the medical record found a current physician's orders [REDACTED]. Instructions: Perform right hand hygiene and PROM (passive range of motion) prior to splint application. Start PROM at shoulders and work towards hands/fingers. Perform 3 X (times) 10 with PROM. Apply splint. Goal: Patient will tolerate right hand WHFO (wrist, hand, finger, orthotic) 6 hours per day - off for self feeding. Patient will tolerate PROM and gentle stretch at end of range of motion to bilateral upper extremities. A review of the daily restorative nursing record for November 2013 found instructions to apply the splint at 8:00 a.m. and to remove the splint at 2:00 p.m. Review of the resident's current care plan on 11/06/13, found the following care plan related to prevention of contractures: The focus: Restorative splint and brace assistance: Patient cannot apply and remove the splint/brace Functional deterioration. The goal, Prevent contractures and maintain skin integrity x 6 days per week. The interventions associated with this goal were: Inspect skin daily for signs of redness or irritation. Inspect splint daily. Perform hand hygiene prior to splint application. Perform passive range of motion exercises to bilateral upper extremities prior to splint application. RNA (restorative nursing assistant) program for splinting of right hand 6 days per week. Evaluate skin before splint application and upon removal to check for signs of skin irritation. Provide hand over hand guidance to perform activity. Demonstrate movements as needed. Provide verbal cues to prompt patient. Set up equipment and supplies. The care plan failed to include all the instructions detailed in the physician's orders [REDACTED].>- How many hours a day the resident would wear the splint, the time frame in which the splint would be applied and removed; - PROM (passive range of motion) would start at the shoulders and work towards hand and fingers and perform 3 x 10 with PROM; and - Removal of the splint during meal times. Observation of the resident, at 1:57 p.m. on 11/05/13, found the resident was not wearing the splint. Further observation of the resident, on 11/06/13 at 1:15 p.m.,found the resident in her room with the hand splint lying on the her bed. The resident said she had removed the hand splint herself because she did not want to wear it. Employee #52, the restorative registered nurse, was interviewed at 1:20 p.m. on 11/06/13. She stated she had personally applied the resident's hand splint after the noon meal. She stated the resident can and does remove the hand splint. Restorative nursing assistant, Employee #44, was also interviewed at 1:20 p.m. on 11/06/13. She stated the resident can remove the hand splint herself and the resident will also hide the splint. The director of nursing (DON), Employee #74, was interviewed at 1:35 p.m. on 11/06/13. The DON verified the resident could remove the hand splint. On 11/06/13, Employees #62 and #4, both registered nurse care plan coordinators, were interviewed at 1:45 p.m. regarding the resident's current care plan. Employee #4 agreed the current care plan did not include all the specific physician's orders [REDACTED]. She verified the focus problem should state the resident could remove the hand splint, instead of, patient cannot apply/remove the hand splint due to functional deterioration. | 2018-04-01 |
| 6278 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 280 | D | 0 | 1 | FSTL11 | Based on medical record review and staff interview, the facility failed to revise the care plan of one (1) of twenty-four (24) residents when new interventions for an identified problem were implemented. Resident #88 was assessed as being at risk for falls. The facility failed to update the resident's care plan to include all of the interventions being utilized to prevent falls for this resident. Resident identifier: #88. Facility census: 66. Findings include: a) Resident #88 A review of the medical record on 11/07/13 at 3:23 p.m., revealed Resident #88 was sitting in his wheelchair in front of the nurses' desk when he slid out of his wheelchair and onto the floor at 9:55 p.m. on 10/30/13. According to the record, this was witnessed by staff. Employee #1 (assistant director of nursing) said after this fall, the facility had put Dycem (non-slip material that helps to effectively grip and hold items in place) between the bottom of the cushion and the wheelchair seat in the resident's wheelchair. A review of the resident's care plan for falls, created on 10/16/13, revealed the resident's care plan had not been revised to reflect the use of Dycem as a part of the plan for falls prevention. On 11/07/13 at 4:00 p.m., Employee #1 was informed that the resident's care plan did not include the Dycem intervention. | 2018-04-01 |
| 6279 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 312 | D | 0 | 1 | FSTL11 | Based on observation, medical record review, review of shower sheets, and staff interview, the facility failed to ensure a resident, who was totally dependent upon staff for activities of daily living (ADL) care, was free of odors. The resident did not receive scheduled showers and no efforts were made to address possible refusal of showers or how the facility would maintain good personal hygiene for this individual. This was true for one (1) of four (4) residents reviewed for activities of daily living (ADL) care during Stage 2 of the Quality Indicator Survey. Resident identifier: #6. Facility census: 66. Findings include: a) Resident #6 Observation of the resident during meal time, on 11/04/13 at 11:45 a.m., by (3) three surveyors, found the resident had a strong, foul urine odor. The urine odor was so strong it could be detected when the surveyors were at least five (5) feet from the resident. Observation again, at 12:10 p.m. on 11/07/13, found the resident was sitting directly beside the front door of the facility. Three (3) surveyors again detected a strong urine odor emanating from this resident. Review of the resident's bathing schedule with Employee #4, the registered nurse care plan coordinator, at 9:00 a.m. on 11/08/13, found the resident was to receive showers on Mondays and Thursdays by the night shift nursing assistants (11:00 p.m. to 7:00 a.m. shift). Further review of the documentation on the daily ADL record, by the night shift nursing assistants on 11/07/13, found the resident's last shower occurred on 10/17/13. The resident's current minimum data set (MDS), a quarterly MDS with an assessment reference date (ARD) of 08/21/13, was reviewed on 11/08/13. The resident was coded as being always incontinent of urine in Section H, bowel and bladder, and totally dependent upon staff for showers in Section G, bathing. The director of nursing (DON) was interviewed at 9:20 a.m. on 11/08/13. The observations 11/04/13 and 11/07/13 were discussed with the DON. She stated she would see if she had any documentation that the resident had refused to shower. At 9:42 a.m. on 11/08/13, the DON returned with shower sheets, dated 10/21/13, 10/24/13, and 10/31/13, containing information about this resident and other residents who were to be showered on these dates. The shower sheets were stored in a file cabinet in the DON's office and were not a part of the medical record. According to the shower sheets, the resident had refused a shower on 10/21/13, 10/24/13, and 10/31/13. She agreed the facility had not addressed the resident's refusal to shower. The DON stated she did not realize the resident had begun refusing showers until it was brought to her attention by the surveyor. | 2018-04-01 |
| 6280 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 315 | D | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to ensure a resident, who had a decline in bladder functioning shortly after admission to the facility, received a thorough assessment to determine if any services could be provided to restore or improve bladder functioning. This was true for one (1) of three (3) residents reviewed for urinary incontinence. Resident identifier: #19. Facility census: 66. Findings include: a) Resident #19 Review of the medical record, on 11/07/13, found the resident was admitted to the facility on [DATE]. This was the resident's first admission to the facility. The admission minimum data set (MDS), with an assessment reference date (ARD) of 07/29/13, was coded to indicate the resident was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) in Section H0300, urinary continence. The next MDS, a fourteen (14) day assessment, with an ARD of 08/03/13, found the resident's urinary continence had declined to always incontinent (no episodes of continent voiding) in Section H0300, urinary incontinence. Both the admission MDS and the fourteen day MDS found the resident was totally dependent upon two (2) staff members for toileting in Section G, functional status of the MDS. On 07/24/13, a urinary incontinence evaluation was completed by a registered nurse. The actions identified on the assessment were, If no clinical symptoms or transient / reversible causes identified OR unable to be reversed ( e.g. meds cannot be changed), urinary incontinence is persistent. Initiate Three - Day Continence Management Diary and complete Urinary Incontinence Nursing Interventions. Further review of the Urinary Incontinence Evaluation found no clinical factors or transient / reversible factors were identified as contributing to the urinary incontinence. Review of the facility's policy titled, Continence Management, found, The Urinary Incontinence Assessment and / or Bowel Retraining Assessment and the Three - Day Continence Management Diary will be completed if the patient is incontinent upon admission or re-admission and with a change in condition or change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment. On 07/27/13 another Urinary Incontinence Nursing Interventions assessment was completed by a registered nurse. The resident was identified as having functional incontinence. According to the guidance to surveyors for this regulation, . functional incontinence refers to loss of urine that occurs in residents whose urinary tract function is sufficiently intact that they should be able to maintain continence, but who cannot remain continent because of external factors (e.g. inability to utilize the toilet facilities in time). The assessment identified the action taken after completion was, individually selected absorbent products. At 10:21 a.m. on 11/07/13, Employee #4, the registered nurse care plan coordinator, stated a three (3) day voiding diary could not be located for this resident. She stated the diary could be misfiled in another record. At the close of the survey on 11/08/13, no further information had been provided regarding the diary. Employee #4 agreed, on 11/07/13 at 10:21 a.m., a three (3) day voiding diary should have been completed for the resident. She was unable to provide any interventions taken by the facility to restore or improve the resident's urinary incontinence. She added the purpose of the voiding diary was to determine whether the resident would benefit from a toileting program. Without the three (3) day voiding trial, there was no data to analyze to determine whether the resident had an identifiable pattern upon which an individualized toileting program might be developed to assist the resident in regaining some degree of continence. | 2018-04-01 |
| 6281 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 329 | D | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that each resident's medication regimen was free of unnecessary medications. Two (2) of five (5) residents reviewed for unnecessary medications were found to be receiving antipsychotic medications without adequate indications for its use. Resident #1's [MEDICATION NAME] dose was increased without evidence of behaviors indicating a need for an increased dose. Resident #4 received an increase in the dose of [MEDICATION NAME] without evidence warranting the increase of [MEDICATION NAME]. Resident identifiers: #1 and #4. Facility census: 66. Findings include: a) Resident #1 Medical record review, on 11/06/13 at 8:45 a.m., found the resident was prescribed the medication [MEDICATION NAME] 0.5 milligram (mg) by mouth every twelve (12) hours for hitting, kicking, and yelling, related to chronic [MEDICAL CONDITION] disorder. A review of the resident's care plan found the resident had a history of [REDACTED]. The behavior monitoring logs for the months of August, September, and October 2013 indicated staff were monitoring for the behaviors of hitting, kicking, yelling and cursing. The logs did not identify the resident had exhibited any behaviors during this period. The pharmacist had completed monthly medication regimen reviews with recommendations for gradual dose reductions. A dose reduction recommendation for the medication [MEDICATION NAME] was made 07/25/13. The physician accepted the recommendation on 08/20/13, decreasing the dose from [MEDICATION NAME] 0.5 mg two (2) times a day to [MEDICATION NAME] 0.25 mg two (2) times a day. The psychiatric physician saw the resident on 09/08/13 and increased the resident's [MEDICATION NAME] back to 0.5 mg twice a day. The physician made a note stating the following; According to the staff, she has had episodes where she was screaming, cursing the staff, and was having some hallucinations or delusions. A review of the resident's nursing notes revealed only one (1) episode of cursing. This episode, dated 08/12/12, was prior to the dose reduction of [MEDICATION NAME] on 08/20/13. In an interview with the director of nursing (DON), on 11/06/13 at 9:20 a.m., she stated the resident would frequently turn on the staff and begin to yell at them. The DON was asked to look at the behavior logs to verify that no behaviors were documented. She did look at the behavior logs and could not identify any behaviors. At 10:00 a.m. the DON returned and stated she was unable to locate any documentation to support the increase on 09/08/13 in the [MEDICATION NAME]. b) Resident #4 Medical record review found the resident was receiving the antipsychotic medication, [MEDICATION NAME], for a [DIAGNOSES REDACTED]. had been increased from 2.5 mg. twice a day (BID) to 5.0 mg. BID on 09/08/13. Further review of the medical record found a psychiatric consult completed on 09/08/13 which revealed the psychiatrist had recommended an increase in the [MEDICATION NAME] and had documented, .According to staff, she continues to have active hallucinations Review of the psychoactive medication monthly flow sheets for August 2013 and September 2013 found the resident was receiving [MEDICATION NAME] for a [DIAGNOSES REDACTED]. According to the daily documentation on the psychoactive medication monthly flow record,the staff had recorded the resident as having no delusions or paranoia for the months of August September 2013. Nursing progress notes were also reviewed for August and September 2013. There was no evidence the resident had exhibited any behaviors during this time frame. At 10:00 a.m. on 11/06/13, the director of nursing (DON) confirmed she was unable to find any documentation the resident had exhibited any hallucinations to warrant the increase of [MEDICATION NAME]. | 2018-04-01 |
| 6282 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 371 | F | 0 | 1 | FSTL11 | Based on observation and staff interview, it was determined the facility failed to maintain a sanitary environment in the kitchen. Drinking glasses were not adequately air dried to prevent moisture from being trapped inside the glasses. This created a potential for the growth of microorganisms. This practice had the potential to affect all residents who received meals from the kitchen. Facility census: 66. Findings include: a) During the initial tour of the dietary department, beginning at 11:23 a.m. on 11/04/13, the following sanitation infraction was observed with the dietary manager, Employee #41. 1) Observation of a small storage cabinet, mounted on the wall of the kitchen, at 11:30 a.m. on 11/04/13, found drinking glasses had been stacked together before air drying. There was moisture trapped between the glasses. When the glasses were picked up, rings of water were visible on the shelf. The dietary manager stated she would wash the glasses again. | 2018-04-01 |
| 6283 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2014-07-25 | 282 | D | 0 | 1 | OTV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to implement the care plan for one (1) of eighteen (18) residents whose care plans were reviewed. Resident #37 had a [MEDICAL CONDITION] due to a fall. The care plan for falls included maintaining a clutter free environment, which was not implemented. A bedside table was observed covering approximately one-third of the fall mat. Resident identifier: #37. Facility census: 68. Findings include: a) Resident #37 Resident #37 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 07/02/14, assessed this resident was moderately impaired with regards to cognition with total dependence on two (2) staff for physical assistance with bed mobility and transfers. In an interview with licensed practical nurse (LPN) #46 on 07/21/14, the LPN stated the resident had a [MEDICAL CONDITION] within the previous 30 days as a result of a fall. Review of the resident's current care plan revealed a plan for falls prevention with interventions to maintain a clutter free environment, low bed, and fall mats next to the bed. Observation of the resident on 07/22/14 at 10:55 a.m. revealed the resident was in a low bed with fall mats next to the bed; however, there was a bedside table placed next to the bed which covered approximately the upper 1/3 of the fall mat. In an interview with the Director of Nursing (DON) #66 on 07/22/14 at 11:02 a.m., the DON verified the placement of the bedside table over the fall mat and stated the bedside table should not have been placed over the fall mat. Nurse aide (NA) #11, on 7/22/14 at 11:30 a.m., stated she had not placed the bedside table over the fall mat next to the bed. The NA stated that perhaps the staff that had assisted resident to eat her ice-cream had not repositioned the bedside table appropriately. NA #11 stated fall mats should be unobstructed and clear of bedside tables. | 2018-04-01 |
| 6284 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2014-07-25 | 323 | E | 0 | 1 | OTV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, and record review, the facility failed to ensure the environment remained as free from accident hazards as possible. Two (2) (#2 and #53) of four (4) residents reviewed for accidents had bed rails that were ill-fitting. Additionally, the facility failed to ensure one (1) medical supply closet with hazardous chemicals was locked. These issues had the potential to affect more than a limited number of residents. Resident identifiers: #2 and #53. Facility census: 68. Findings include: a) Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), dated [DATE], found Resident #2 was cognitively impaired, dependent on the assistance of two (2) staff members for bed mobility, and had functional limitation in range of motion to both bilateral upper and lower extremities. Review of the current physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the activity of daily living records for May, June, and July 2014 revealed Resident #2 was dependent on the assistance of two (2) staff for bed mobility. Observations, on 07/22/14 at 10:05 a.m., revealed Resident #2 was in her bed with bilateral half side rails in the up position and the air mattress in place on the bed. There were gaps noted between both of the side rails and the outer sides of the air mattress. The gaps measured 5 1/2 inches and the mattress was noted to have a slick surface. During this observation the resident was noted to be in a fetal position. She was positioned with pillows that were partially covering the gap between the side rail and the side of the air mattress. Interview with Nurse Aide (NA) #23 and NA #95, at the time of the observation, revealed they place the pillows bedside the resident to position her hands and arms due to contractures. They both stated they did not attempt to position the pillows to decrease the amount of space between the side rail and the air mattress, but said the way they had to place the pillows always covered the gaps and prevented the resident from sliding into the gaps. They also stated Resident #2 was unable to reposition herself or move her upper body and stated she was totally dependent on the staff to move her. Observation on 07/22/14 at 12:02 p.m., revealed Resident #2 was noted to be out of her bed and in her wheelchair. Observation on 07/22/14 at 2:30 p.m. revealed the Resident #2 was in bed on her right side. There was a pillow between her and the bed rail, but the gaps were still noted between the bed rail and the mattress. On 07/22/14 at 2:45 p.m., this surveyor shared with the Director of Nursing (DON) #66, the observations of the gaps noted on Resident #2's bed between the side rails and the mattress. The DON stated all of the beds with air mattresses were required according to manufacturer's recommendation to have side rails on the bed. The DON accompanied this surveyor to Resident #2's room to observe the gaps noted between the side rails and the air mattress. She verified there were gaps between the rails and the air mattress that could pose an entrapment risk for Resident #2. The DON stated Resident #2 was not able to move her upper body on her own, but confirmed if the pillows were not in place for positioning the resident's arms, the resident could potentially slide into the gaps between the side rail and the air mattress. The DON advised staff to obtain wedge devices to place between the gaps between the side rail and the mattress while they further assessed the use of the side rails. The decision was made at that time to change the bed and the air mattress. This was done immediately. It was verified by observation that the bed, mattress, and rails were replaced. After Resident #2 was placed in the new bed, it was determined there were no longer any concerns about the safety of the bed for this resident. The DON was asked whether she could provide the written manufacturer's recommendation regarding the use of the side rails with the air mattress on Resident #2's bed. At 3:05 p.m. on 07/22/14 the DON #66 stated she had called the mattress manufacturer, but they were unable to provide her documentation to indicate the necessity or directive to always use side rails on a bed with their air mattress product. She was also unable to provide a facility policy that addressed the use of side rails on beds when utilizing an air mattress. b) Resident #53 Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her most recent Minimum Data Set (MDS), dated [DATE], found Resident #53 was assessed as cognitively intact and was dependent on two (2) staff for bed mobility and transfers from the bed to her motorized wheelchair. Her functional limitation in range of motion was documented as having no impairment to her upper extremities, but she was noted to have impairment to both lower extremities. Review of the Resident #53's current activity of daily living (ADL) care plan dated 03/17/14 documented an intervention to use bilateral half side rails on her bed as ordered as an enabler for turning and repositioning while in bed. The bed safety action grid used to assess the safety of the bed rails used on Resident #53's bed was dated 03/14/14. This assessment grid documented there were no potential entrapment concerns related to the use of the bed rails on the bed. Observation of Resident #53 on 07/21/14 10:39 a.m. revealed she was in bed with bilateral half side rails in the up position. The side rail on the bed located to the resident's left side was leaning out away from the resident. There was a gap between the air mattress and the bilateral half side rails on the bed. Interview with the resident at this time revealed she used the side rails to assist in repositioning herself in the bed. Observation again on 07/22/14 at 9:00 a.m. revealed Resident #53 was in bed and the left side rail was leaning away from the resident. Interview with the Resident #53 at that time revealed she had good upper body strength and stated she does use the side rails on her bed for positioning. She stated she cannot use her lower extremities due to being a paraplegic so the rails are very helpful for her to help herself turn in the bed. She demonstrated at this time how she used the side rails. When she reached for the side rail to her left, and the rail was noted to be very loose and moved back and forth when the resident was pulling on it. There was a large gap also noted between the side rail and the air mattress when the rail leaned outwardly away from the bed. Interview with Resident #53 during this observation revealed she had good upper body strength and if her arm, shoulder, or head got close to the noted gap between the air mattress and the side rail she would be able to pull herself back over. She did state that the left side rail had been loose for awhile and she did use it often for repositioning herself. Interview with Nurse Aide (NA) #23 on 07/22/14 at 10:35 a.m. revealed she was not aware of any concerns with the bed rails currently in place on Resident #53's bed. She stated the resident was capable and did frequently use the bed rails to assist with repositioning herself in the bed. Interview with licensed practical nurse (LPN) #46 on 07/22/14 at 11:16 p.m. revealed it is the facility's policy to use side rails on all beds when an air mattress is in use. Interview with Director of Nursing (DON) #66 on 07/22/14 at 3:00 p.m. revealed all facility beds with air mattresses on them were required by manufacturer recommendations to have rails on the bed. The DON stated it was also the facility policy that the beds with air mattress on them were equipped with side rails. The DON was asked to observe the side rails currently being used on Resident #53's bed. During this observation she verified there were gaps (6 inches) between the mattress and the bed rail on the left side and that the rail was extremely loose causing it to lean outward away from the resident. She again stated that it was corporate policy that all of their beds with air mattresses have bilateral 1/2 side rails on the bed for safety. This surveyor asked if she could provide the written manufacturer's recommendations and to evaluate any current safety risk for Resident #53 with the use of loose side rail on her bed. At 3:40 p.m. on 07/22/14 p.m. the DON stated the air mattress company was unable to provide documentation stating the requirement for side rails to be used with the use of their mattress. She stated she had notified the maintenance staff of the loose side rail on Resident #53's bed and the rail would be replaced. At 4:02 p.m. on 07/22/14, the DON #66 and the Administrator #65 observed Resident #53's bed and the loose bed rail causing a gap between the bed rail and air mattress. They both agreed the bed rail was very loose and allowed for the rail to fall outwardly causing a gap between the mattress and the rail. They also agreed that this could potentially pose an entrapment and potential injury to Resident #53 if the rail became dislodged. The gap was noted to measure six (6) inches. The Administrator #65 stated the maintenance staff would fix the loose bed rail immediately . Interview with Nurse Aide (NA) #16 and NA #95, who provide care to Resident #53 on 07/22/14 at 3:44 p.m., revealed if they noted a problem or concern with side rails not fitting the bed properly or a broken or loose side rail they would fill out a maintenance slip and turn it in to be repaired. They stated they had not noted any concerns with Resident #53's side rails on her bed. Interview with the maintenance personnel #73 on 07/22/14 at 4:30 p.m. revealed he did not have a system in place where he routinely checked the side rails on the residents' beds in the facility. He stated he relied on the staff to notify him if there was a concern that needed his attention. He observed the side rail on Resident #53's bed and stated the rail was broken and needed to be replaced. c) The facility checked all resident with air mattresses and side rails to ensure there were no other problems with gaps between the mattresses and side rails. None were found at that time. Bed rail safety assessments were completed for all residents with side rails and air mattresses. No additional issues were identified. d) Medical Supply Closet: During the initial tour of the facility on 07/21/14 at 8:30 a.m., a medical supply closet was noted to be unlocked on the 300 hall. The closet was identified to have chemicals and razors located on the shelves in the room and accessible to residents who may attempt to go into the the room. Staff #75, the scheduling coordinator was immediately notified of this closet being unlocked and she stated the door was to be locked at all times and confirmed they had residents who may wander into the unlocked closet. The chemicals noted to be accessible were five bottles of Skintegrity wound cleaner and the material safety data sheet (MSDS) indicated if this was to be ingested vomiting should be induced and the physician should be notified immediately. One bottle of isopropyl rubbing alcohol 70% was noted and the MSDS indicated if this was swallowed vomiting should be induced and the physician should be notified immediately. Interview with the Director of Nursing (DON) #66 on 7/21/14 at 10:00 a.m. revealed this closet should remain locked at all times to prevent residents from entering the area. She verified they did have residents that were confused and wandered and could potentially enter the room if it was unlocked. | 2018-04-01 |
| 6285 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2014-07-25 | 428 | D | 0 | 1 | OTV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to act upon the consultant pharmacist's recommendation for one (1) of five (5) residents whose medications were reviewed. Although the director of nursing (DON) and the physician had signed acknowledgement of the pharmacist's recommendations, a reduction in the dosage of a medication had not been implemented. Additionally, the pharmacist's recommendation for documenting the risks and benefits of continuing dual therapy had not been addressed. Resident identifier: #79. Facility census: 68. Findings include: a) Resident #79 Review of the resident's medical record, at 10:00 a.m. on 07/23/14, noted Resident #79 was admitted to the facility on [DATE], and had multiple [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#79 had an order for [REDACTED].>A review of the consultant pharmacist's report for the month of June 2014 revealed the pharmacist had recommended, Please re-evaluate the need for both antidepressants, perhaps giving consideration to reducing Trazodone to 25 mg at bedtime. Additionally, the section of the consultant pharmacist's report entitled Physician's Response revealed a checkmark next to the statement, I accept the above recommendation(s) above, please implement as written. The physician also wrote a note on the same consultation form to reduce the other antidepressant Remeron from 30 mg to 15 mg. The consultant pharmacist report was signed by both the physician and the Director of Nursing (DON) #66 on 06/16/14. A review of the June 2014 Medication Administration Record [REDACTED]. That order originated on 06/17/13 during the resident's admission to the facility. Further review of the MAR indicated [REDACTED]. The consultant pharmacist's report also included, If dual therapy is to continue, it is recommended that the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual. There was no risk versus benefit assessment found in the clinical record. An interview was conducted with the DON on 07/23/14, at approximately 10:45 a.m., regarding the recommendation to reduce the Trazodone from 50 mg to 25 mg. The DON acknowledged that her signature was on the consultant pharmacist's report with the recommendation to reduce the Trazodone from 50 mg to 25 mg. The DON stated, Okay, I see. The DON later returned on the same day, at approximately 11:25 a.m., with Unit Manager #80 who stated that the physician had possibly changed her mind and only wanted to reduce the Remeron instead of the Trazodone. Unit Manager #80 stated she had not clarified the order with the physician, and stated that the physician probably made a mistake. By mistake the Unit Manager #88 voiced that the physician probably meant to check the other box on the pharmacist's consultant report which stated, I accept the recommendation(s) above WITH THE FOLLOWING MODIFICATION(S): | 2018-04-01 |
| 6286 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2014-07-25 | 514 | D | 0 | 1 | OTV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain organized medical records for two (2) residents who were receiving [MEDICATION NAME] therapy. Documents pertaining to Resident #103 were found in Resident #93's medial record. Two (2) of twenty-four (24) Stage 2 sample residents were affected. Resident identifiers: #93 and #103. Facility census: 68. Findings include: a) Resident #93 Review of the resident's medical record, on 07/23/13, at 9:30 a.m., found Resident #93 was readmitted to facility on 05/05/14. The resident had multiple [DIAGNOSES REDACTED]. Resident #93 resided on the 400 hallway of the facility. Resident #103 was also a resident in the facility, and resided on the on the 200 hallway of the facility. Upon review of the medical record for Resident #93, thirteen (13) medical record documents for Resident #103 were found within the medical record of Resident #93. Those thirteen (13) documents included the following: -- Nine (9) pages of medication administration records (MAR's),with numerous order changes; -- One (1) PRN (as necessary) sheet; -- One (1) Flow sheet for monitoring customers taking [MEDICATION NAME], with numerous order changes; -- One (1) psychoactive medication monthly flow record; and -- One (1) peripheral catheter treatment record. In and interview with the director of nursing (DON), on 7/23/2014 at approximately 10 a.m., she stated she was aware on the previous day that there were documents in Resident #93's chart that actually belonged to Resident #103. The DON stated she was not sure how the documents for Resident #103 actually ended up within the medical record of Resident #93. The DON also stated when she made the copies of the documents for this surveyor, she noticed the error and further stated she had removed the 13 documents after noticing they belonged to Resident #103, not Resident #93. An interview was also conducted with the 400 hall Unit Manager #80 on 07/23/14 at 2:00 p.m. Unit Manager #80 was assigned to care for Resident #93 who resided on the 400 hall of the facility. Unit Manager #80 stated she was unsure how this mix up occurred, as the residents resided on two (2) different hallways. She commented, I'm thinking they were in a collaborative chart and then just filed wrong. She went on to say, We audited the charts for the two residents (#93 and #103) after discovering the error yesterday, and all of the orders and INR's (International Normalized Ratios) matched for both residents. Unit Manager #80 also stated there were about about ten (10) days of overlap when both residents were on [MEDICATION NAME] therapy and having their INR labs drawn with multiple order changes. Again she re-iterated that upon the audit of both medical records, all of the physician's orders [REDACTED]. | 2018-04-01 |
| 6287 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2014-06-04 | 309 | J | 0 | 1 | 7QU811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to ensure a resident received the necessary care and services to maintain the highest practicable physical, mental and psychosocial well being, in accordance with the comprehensive assessment. On 05/28/14, one (1) of five (5) residents with food allergies (Resident #249) was served food to which he was allergic. This situation was determined an immediate jeopardy (IJ), requiring an immediate plan of correction (P(NAME)) by the facility. The facility implemented an appropriate P(NAME) at 7:36 p.m. on 05/28/14; however, the P(NAME) was not implemented the following day, 05/29/14, resulting in continuing non-compliance at an IJ level. The continuing non-compliance affected one (1) of four (4) residents with allergies, who remained in the facility (Resident #264). The continued non-compliance as a result of the IJ was abated at 3:36 p.m. on 05/29/14. The scope and severity was then reduced to a D. Resident identifiers: #249 and #264. Facility census:23. Findings include: a) Resident #249 During a conversation with Resident #249, on 05/28/14 at 9:15 a.m., he asked, Can you do me a favor? The resident said he received grape jelly on his tray, and said he was very allergic to it. He requested it be disposed of and requested strawberry jelly. Review of the tray ticket, found it identified he was allergic to grape. He had one (1) packet of reduced sugar grape spread on his tray. The resident added, It is on my record, I am not allowed to have it. My lips would swell turn inside out, my eyelids would swell shut, and my tongue would swell. The case manager, Employee #22 , a registered nurse (RN), reviewed the tray ticket at 9:25 a.m. on 05/28/14. The RN confirmed the resident had an allergy to grapes, and disposed of the grape jelly. On 05/28/14 at 9:50 a.m., three (3) nursing assistants (NAs), Employees #69, #70, and #31 (NA) said nursing assistants' responsibilities included reviewing the tray ticket to ensure residents received the items ordered and received the correct diet. They indicated diet restrictions were noted at the bottom of the tray ticket, and included any restrictions and allergies. Employee #69 said the NAs compared the tray tickets when the trays were passed to the residents. Upon request, at 10:15 a.m. on 05/28/14, the director of nursing (DON) arranged an interview with the dietary manager, referred to in the facility as the food service supervisor (FSS). Review of the medical record, at 10:30 a.m. on 05/28/14, revealed an order summary which noted Resident #249 had an allergy to grapes, and anything with grapes in it .such as juices. Pt states he has a severe reaction to them. It was dated 05/20/14, the date of admission to the facility. Another entry noted the reaction was throat swelling. Additionally the resident's face sheet noted ALLERGIES: GRAPES. An interview with Employee #10, the FSS, on 05/28/14 at 10:45 a.m., revealed the dietary department obtained resident information via the electronic system. She indicated allergies were entered into the system by the nurse. The FSS related the galley technician obtained any other food preferences (and allergies if information was obtained) and made a note of that. She said this information was entered into the dietary system. The FSS said whomever was working in dietary had access to the information. She said allergies and preferences were entered into the system in separate places and only allergies were printed on the tray ticket. The FSS related, before assembling the trays, staff . matched the ticket with the diet sheet to make sure it was kosher. She said a second check was completed on the tray line before meal assembly. Employee #10 said tray tickets were printed in the morning and staff were kept updated on any changes throughout the day. During a second interview, at 11:00 a.m. on 05/28/14, the FSS provided a census report which noted: Allergy: NO GRAPE. She confirmed the facility was aware the resident had an allergy to grape, and the resident should not have received the grape jelly. Another interview was conducted with the FSS in the kitchen, at 12:15 p.m. on 05/28/14. She related, The girl picked up the wrong one. because they were obtained from a box containing a variety of flavors. The FSS presented a box of jelly with a mixture of blackberry, grape, and strawberry flavored spreads. The content label on the grape spread (jelly), reviewed with Employee #10, revealed it contained Concord grape juice concentrate and concord grape puree concentrate. A meeting was requested with the administrator (ADM) and director of nursing (DON) at 12:55 p.m. The ADM and DON were notified , on 05/28/14 at 1:15 p.m., of an immediate jeopardy related to Resident #249's receipt of grape jelly. They indicated they were aware of the concern, and the FSS had . already begun to put together a plan of correction. The P(NAME) of correction was accepted and the immediate jeopardy was abated at 7:36 p.m. on 05/28/14. b) Resident #264 (Continued Non-Compliance) Follow up food delivery observations, related to the immediate jeopardy identified on 05/28/14, were completed on 05/29/14. A lunch observation revealed the P(NAME) was not implemented. According to the P(NAME), the facility would highlight the food tray ticket to alert staff of a food allergy. Observation of Resident #264's tray ticket revealed the resident's food allergy to [MEDICATION NAME] was not highlighted on the tray ticket. The tray ticket was immediately presented to the administrator. He reviewed the tray ticket, confirmed staff did not highlight the allergy, and confirmed a failure to implement the P(NAME). A status of continued non-compliance was instituted at that time. According to the P(NAME), the tray line ticket review would include highlighting allergies with a highlighter marker and carefully reviewing the ticket for not allowed items. This portion of the plan to abate the IJ was not implemented, as Resident #264's food allergy was not highlighted. As part of the P(NAME), nurses, nursing assistants, and housekeepers were educated, on 05/28/14, to check resident tray tickets for allergies that would be highlighted. The FSS had also educated dietary staff on the procedures. The in-service provided to dietary staff indicated, Beginning 05/28/14 . at each meal, all tray tickets are checked to assure food allergies are printed on each tray ticket. The allergy is highlighted with a highlighter pen . The employee that checks the tray ticket will initial the ticket that it has been checked for food allergy compliance. All tray line workers will check each ticket for the highlighted food allergy . the tray line checker will check the tray for the highlighted food allergy. During a follow up interview on 05/29/14 at 1:00 p.m., the administrator confirmed the facility had not implemented the procedure. Observation revealed the continued non-compliance was abated on 05/29/14 at 3:36 p.m., when the facility implemented the plan of correction as indicated. Subsequent observations also revealed the P(NAME) was effectively implemented, and compliance was maintained. | 2018-04-01 |
| 6288 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2014-06-04 | 371 | E | 0 | 1 | 7QU811 | Based on observation and staff interview, the facility failed to ensure foods were served under conditions which reduced the potential for foodborne illness. Plastic drinking cups were stacked inside of each other prior to air drying, creating a medium for the growth of bacteria. This practice had the potential to affect more than a limited number of residents who received nourishment from the dietary department. Facility Census: 23 Findings Include: a) On 05/27/14 at 10:15 a.m. the initial tour of the kitchen began. Employee #10, Director of Food Services (DFS), guided the tour. At 10:45 a.m., a cart was observed being taken from the dishwashing area. Two (2) inverted, nested stacks of plastics drinking cups were observed on the cart. The two (2) stacks were comprised of four (4) cups each, for a total of eight (8) cups. The cups were observed wet on the inside, creating a medium for the growth of bacteria. Employee #10 separated two (2) of the cups, and agreed they were not air dried prior to stacking them together. She said the cups should have stayed on the drying rack longer, and should not have been stacked until they were dry. | 2018-04-01 |
| 6289 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2014-06-04 | 497 | F | 0 | 1 | 7QU811 | Based on employee personnel file reviews and staff interviews, the facility failed to ensure annual performance reviews were completed for each nursing assistant. The facility only completed performance evaluations every three (3) years. This practice had the potential to affect all residents. Facility census: 23. Findings Include: a) Review of personnel files revealed the last annual performance review for Employee #69, a nursing assistant, was completed on 07/25/11. At 3:00 p.m. on 06/03/14, Employee # 2, Human Resources (HR) reported the facility's policy was to complete performance evaluations every three (3) years, not annually. On 06/04/14 at 10:45 a.m., Employee #1 (HR) confirmed the facility policy regarding employee evaluations, stating they were completed every three (3) years. She said she would make the necessary changes to comply with federal regulations where the distinct part of the hospital was concerned. | 2018-04-01 |
| 6290 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 155 | D | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, interviews with the contracted facility staff, and interview with the resident's medical power of attorney, the facility failed to ensure a resident's rights were honored for one (1) of twenty-nine (29) residents reviewed in Stage 2 of the Quality Indicator Survey. The resident received anticoagulant therapy at the [MEDICAL TREATMENT] center. His medical record indicated he did not want anticoagulant therapy due to religious beliefs. Resident identifier: #169. Facility census: 105. Findings include: a) Resident #169 A medical record review, completed on 04/14/14 at 9:00 a.m., revealed Resident #169 received [MEDICAL TREATMENT] services. The current care plan indicated the facility would coordinate care with the [MEDICAL TREATMENT] center. A hospital discharge summary, dated 03/08/14, noted the resident did not receive anticoagulation therapy related to his religious beliefs. In addition, a physician's progress note included, (name of religion) . no anticoagulant therapy. During an interview with the medical power of attorney, on 04/14/14 at 4:30 p.m., she conveyed Resident #169's religious preferences were very important to him. She confirmed he did not want anticoagulant therapy. Upon inquiry, she related she was unaware of the [MEDICAL TREATMENT] process. She said the [MEDICAL TREATMENT] center had spoken with her, but she did not know how the process worked. An interview with [MEDICAL TREATMENT] staff, on 04/14/14 at 5:30 p.m., revealed they were not aware of the resident's refusal of anticoagulant therapy. Staff member #182, a registered nurse (RN) and Staff member #183 (RN) said information regarding the resident's preference for refusal of anticoagulant therapy was not conveyed to them. Employee #183 said communication with the facility was usually limited to communication forms. In addition, the [MEDICAL TREATMENT] center staff related they were not invited, and had never participated in the facility's care plan process. Employee #182 explained options, other than [MEDICATION NAME], were available for the resident, such as saline flushes. Review of the agreement between the facility and the outpatient [MEDICAL TREATMENT] services revealed the facility would make the necessary individual resident clinical records available as necessary for the [MEDICAL TREATMENT] center to furnish its services. The director of care delivery (DCD), Employee #101, was interviewed on 04/15/14 at 8:30 a.m. regarding what pertinent information was shared with the [MEDICAL TREATMENT] center. She said the information provided to the [MEDICAL TREATMENT] center consisted of a copy of the Medication Administration Record, [REDACTED]. There was no evidence the hospital discharge summary, dated 03/08/14, which noted the resident did not receive anticoagulation therapy related to his religious beliefs, or the physician's progress note which included (name of religion) . no anticoagulant therapy were shared with the [MEDICAL TREATMENT] center. Upon exit, the facility had provided no evidence to indicate an attempt was made to ensure Resident #169's right to refuse treatment in regards to religious preferences was honored. | 2018-04-01 |
| 6291 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 225 | E | 0 | 1 | ZU6S11 | Based on record review, review of staff training records, employee personnel file review, review of incident documentation, and staff interview, the facility failed to report and investigate an allegation of resident neglect. The resident was improperly lifted with a mechanical lift, resulting in a fall. In addition, the facility failed to ensure a pre-employment statewide criminal background check was completed for one (1) of five (5) newly hired employees. These practices had the potential to affect more than an isolated number of residents. Resident identifier: #30. Employee identifier: #35. Facility census: 105 Findings include: a) Resident #30 The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. When examined, a nurse noticed the resident's left leg was a different length than the right leg. The resident complained of pain in her leg, hip, and back when she was moved. The resident was transported to an acute care hospital. The hospital found no evidence of a fracture and there was no evidence the pain persisted. A review of an incident report, with an incident date of 04/04/14, for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand using the Sara 3000 lift to enable staff to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m. with Employee #159, a nursing assistant (NA). During the interview, she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the resident's mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) arm under the sling, and fell to the floor. Employee #159 was asked to explain the procedure for using the Sara 3000 lift. She stated they were to put the sling around the resident's mid-torso region and snap the buckles on the sling into place. She stated they then attached the clips from the sling to the attachment on the lift. During the interview at 1:45 p.m. on 04/09/14, Employee #159 stated there were no buckles on the sling to snap Resident #30 in place around the mid-torso region. She confirmed she knew she was supposed to snap the buckles to hold the resident in place. When asked if she had identified the buckles were missing while she was standing Resident #30, she stated she did not notice the buckles were missing from the sling. The NA stated she did not think Employee #33 knew either, because she did not say anything to her while they were attempting to use the Sara 3000 lift. An interview was conducted with Employee #16, the direct care delivery (DCD) nurse, on 04/09/14 at 2:00 p.m., regarding Resident #30's fall. She stated she was called to the room because the resident had slid out from under the sling while the NAs were attempting to stand the resident. Employee #16 stated the resident complained of pain in her right hip and the physician was notified. She said the resident was transferred to an acute care hospital for evaluation. Employee #16 said the resident returned at a later time that day with a recommendation to follow up with a CAT scan (Computerized Tomography (CT scan)) for her hip and her head. The DCD was asked what had caused the fall. She stated the buckles were cut off the sling so there was nothing to hold the resident in the Sara 3000 lift. The DCD was asked who trained the employees on the use of the Sara lift. She stated training was provided by the company from whom the facility purchased the lifts. The DCD stated upon hire, all nursing staff must watch a video on how to use the different types of lifts in the facility. She stated she did not know when the company may have been in to provide any training on how to use the Sara lift. The NA in-service records were reviewed on 04/09/14 at 2:00 p.m. The Sara lift in-services contained no evidence the NAs were evaluated for competency in the use of a Sara 3000 lift. The in-service records contained only signatures which represented the NAs had watched the videos. An interview was conducted on 04/09/14 at 3:38 p.m., with Employee #64, a registered nurse (RN). When asked how Resident #30 fell from the Sara 3000 lift, she stated the resident slid out of the lift. Employee #64 said an aide told her Resident #30 was lying on the floor. She said when she went to assess the resident, she observed Resident #30 lying on her back with her feet toward the window. The resident's assessment revealed she was having pain in her right hip. Employee #64 stated she called the physician, and the physician told her to send the resident to the emergency room for evaluation. Employee #64 said when her hip was touched, the resident said she was having pain. Employee #64 said she reported the fall to Employee #72, the director of nursing (DON). On 04/09/13 at 2:50 p.m., the DON confirmed she was told about Resident #30's fall. She said she looked at the sling, then asked Employees #33 and #159 to tell her how the resident could have possibly fallen out of the sling with the mid-torso buckles in place. She stated when she said this, Employee #159's eyes got real big and Employee #159 walked away. She said Employee #159 returned with the sling and said to the DON, They aren't there. The DON stated she asked the employees, Did you have the buckles hooked to her middle torso? The DON said Employee #33 and #159 stated No. The DON asked the employees why they would you use a sling that did not have the buckles in place. The DON said Employee #159 stated she did not realize the buckles were not there. The DON said she immediately reviewed, with the NAs, the need to check the integrity of all slings prior to putting them around or underneath a resident. She also said she reviewed the proper use of the Sara lift with the NAs. The DON stated she then took the Sara lift and the altered sling, which was used with Resident #30, to the administrator's office and described the accident and the circumstances surrounding the accident to the administrator. During an interview with the DON on 04/10/14 at 8:30 a.m., she was asked if this incident of neglect was reported and investigated as soon as the facility identified the buckles were missing and the NAs confirmed they used the sling without the required buckles. The DON said they they did not report this incident as required. She confirmed the incident was substantiated for failure to utilize the Sara lift sling appropriately on 04/04/14. b) Employee #35 On 04/09/14 at 11:30 a.m., a review of the personnel files for newly hired employees was conducted with Employee #157, the Director of Human Resources. Review of the personnel file for Employee #35, a social worker who was hired on 03/17/14, revealed no evidence of a statewide criminal background check. The Director of Human Resources verified the personnel file for Employee #35 did not contain evidence of a statewide criminal background check. At 12:30 p.m. on 04/09/14, the Director of Human Resources, provided an appointment slip indicating Employee #35 was scheduled for an appointment to obtain the statewide criminal background check on 03/28/14. She agreed this background check was not obtained prior to employment. | 2018-04-01 |
| 6292 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 253 | E | 0 | 1 | ZU6S11 | Based on observation and staff interview, the facility failed to ensure effective maintenance and housekeeping services. The physical environment was not in good repair. Observations revealed peeling paint and wallpaper, broken grout and dark brown substance around the commode, a black substance beneath a heater, and broken wall board with metal exposed. There were also pinholes in a wall, holes around an outlet cover, and a chest of drawers had missing finish and scratches which exposed discoloring. A bathroom mirror was missing the silver backing, and plaster was missing on the corner edge of a bathroom wall, exposing metal. This practice affected nine (9) of sixty-two (62) rooms observed during Stage 1 of the Quality Indicator Survey. Rooms numbers of affected rooms: #207, #208, #211, #214, #305, #309, #312, #409, and #410. Facility census: 105. Findings include: a) Observations of the facility, during Stage 1 of the Quality Indicator Survey, revealed the following rooms had environmental concerns: 1) Room 207: The wall behind the bed had torn wall paper. 2) Room 208: The grout around the commode was broken and a dark brown substance around the commode. A black substance was also observed beneath the heater in the room. 3) Room 211: The grout around the commode was loose, and there was a dark brown substance around the commode. The wall board was broken, exposing 4 inches of metal sheath. There were three (3) areas of peeling paint on the right side of the wall at the entrance of the bathroom. 4) Room 214: The bathroom had scratches and paint peeling halfway up the wall. 5) Room 305: There were multiple pinholes all over the wall. 6) Room 309: Paint was missing on the wall behind the door, measuring three (3) inches long by three (3) inches wide. There were also four (4) holes around an outlet cover. 7) Room 312: The wallpaper was peeling behind the bed. 8) Room 409: The chest of drawers had missing finish on numerous areas on the top and around the bottom. There were scratches on the chest of drawers revealing numerous discolored areas. 9) Room 410: The chest of drawers had missing finish on numerous areas on the top and around the bottom. There were scratches on the chest of drawers revealing numerous discolored areas. The silver backing on the bottom of the bathroom mirror was missing one-fourth (1/4) of the way up the mirror. There was plaster missing on the corner edge of the bathroom wall revealing metal underneath. b) These concerns were discussed and verified with the Maintenance Director, Employee #124, during an interview and a tour on 04/10/14 at 10:30 a.m. | 2018-04-01 |
| 6293 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 258 | D | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to provide comfortable sound levels for one (1) of twenty-nine (29) residents reviewed during Stage 1 and Stage 2 of the Quality Indicator Survey. Resident #120 was disturbed by how loud the television was turned up in room [ROOM NUMBER]. Resident identifier: #120. Facility census: 105. Findings include: a) Resident #120 On 04/08/14 at 10:19 a.m., during Stage 1 of the Quality Indicator Survey, Resident #120 was asked if he had any problem with the temperature, lightening, noise or anything else in the building that affected his comfort. He stated the residents in room [ROOM NUMBER] left their television on all the time, and that he could hear their televisions in his room. He said had reported the problem on several occasions, but could not remember who he had told. An observation and interview was conducted with Resident #120, in his room, on 04/10/14 at 10:15 a.m. The televisions in room [ROOM NUMBER], across the hall, which were on different stations, were so loud they could be heard in Resident #120's room. He stated it was very disturbing to him. During a tour of Resident #120's room, on 04/10/14 at 10:25 a.m., with Employee #124, the maintenance director, he confirmed the television across the hall in room [ROOM NUMBER] was very loud, and could be heard in Resident #120's room. He said they had been this way for sometime. Employee #124 stated the facility was aware of the loud televisions in room [ROOM NUMBER]. He said he was not certain why nothing was done to alleviate the noise problem for Resident #120. | 2018-04-01 |
| 6294 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 279 | G | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure the development of a care plan for one (1) of three (3) residents reviewed for nutritional services, in a total sample of twenty-nine (29) Stage 2 residents. This resulted in actual harm for the resident, who experienced three (3) severe weight losses, each over 5%, in a forty-two (42) day period. Weight loss was indicated on the minimum data set (MDS) assessment; however, the facility failed to care plan for the weight loss until the resident had already experienced an overall weight loss of 15.64% in that forty-two (42) day period. Resident identifier: #147. Facility census: 1 05. Findings include: a) Resident #147 Review of Resident #147's medical record, on 04/10/14 at 9:00 a.m., revealed the resident was admitted on [DATE]. The resident's admission weight was recorded as 104.8 pounds (lbs). The resident's five (5) recorded weights from 11/06/13 to 12/18/14 were as follows: 1. 11/06/13 = 104.8 2. 11/20/13 = 97.6 (loss of 6.87%) The facility rounded this weight up to 98 pounds for the minimum data set (MDS) 3. 11/27/13 = 92.2 (additional loss of 5.3%) 4. 12/04/13 = 94.2 (increase of 2.12%) 5. 12/18/13 = 88.4 (loss of 6.15%) The resident's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/20/13, was reviewed on 04/10/14 at 9:17 a.m. Item K0300, indicating a weight loss of five (5) percent or more in the last month was coded Yes. It also noted the resident was not on a physician-prescribed weight-loss regimen. On 04/15/14 at 11:50 a.m., an interview was conduced with Employee #142, the MDS coordinator. She was asked about the completion of the 11/20/13 MDS and Item K0300 for Resident #147, related to a weight loss of five (5) percent in the last month or a loss of ten (10) percent or more in last six (6) months. Employee #142 said she looked at the weights seven (7) days back from the ARD to determine the weight for the MDS. When asked if she notified other staff members about weight losses she found while doing MDSs, she stated she discussed them during the stand-up meetings. When asked if she put a care plan in place related to weight loss for Resident #147, she stated she did not. Review of the resident's care plan, on 04/10/14 at 9:22 a.m., revealed Resident #147 had no care plan related to weight loss until 02/13/14. The resident experienced a significant weight loss between 11/06/13 and 11/20/13, and again between 12/04/13 and 12/18/13. There was a care plan, initiated on 02/25/14 and revised on 04/03/14, related to the resident's weight loss; however, there was no care plan or interventions related to the three (3) severe weight losses the resident experienced between 11/06/14 and 12/18/13.An interview was conducted with Resident #147 on 04/10/14 at 9:49 a.m. She said when she first came to the facility, she could not eat the food because it was too sweet. She said she had pancakes that morning and could not eat them because the syrup was too sweet. When asked if she had discussed this with the dietary department, she stated they had been told the food was too sweet for her liking. An interview was conducted on 04/14/14 at 11:00 a.m., with Employee #178 (dietitian) and Employee #180 (food service director/general manager). When asked if Resident #147 had a care plan related to weight loss, Employee #178 stated she placed the resident on a supplement on December 18, 2013. She stated she did a care plan, but she thought she had changed the date to a later date somehow, so the initial date was removed. When asked, Employee #180 made no comment about whether she developed a care plan related to weight loss for Resident #147. These employees were unable to provide any additional information when they were informed there was no care plan related to the resident's severe weight losses which occurred between 11/06/13 and 12/18/13. On 04/15/14 at 12:20 p.m., a discussion of Resident #147's weight loss was conducted with Employees #62 (administrator), #178 (dietitian), #179 (dietitian),#101 (director of care delivery), and #72 (director of nursing). When asked what interventions they implemented to prevent further weight loss, no one commented. After the discussion at 12:20 p.m., at 12:30 p.m., an additional review was conducted of the resident's medical record. This review confirmed there was no evidence the facility developed a care plan related to the resident's weight losses which occurred between 11/06/13 and 12/18/13. Between those dates, the resident lost 15.64% of her total body weight. | 2018-04-01 |
| 6295 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 309 | D | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to implement interventions in accordance with a resident's needs, goals, the facility's policies, and in accordance with the comprehensive assessment and plan of care for one (1) of twenty-nine (29) residents reviewed in Stage 2 of the survey. The facility failed to monitor a [MEDICAL TREATMENT] and failed to ensure the resident went to a follow-up appointment related to his [MEDICAL TREATMENT]. Resident identifier: #169. Facility census: 105. Findings include: a) Resident #169 A medical record review, completed on 04/14/14 at 9:00 a.m., revealed a minimum data set (MDS) with an assessment reference date (ARD) of 03/26/14. It indicated Resident #169 had received [MEDICAL TREATMENT] services. Review of the current care plan indicated staff would monitor/assess the [MEDICAL TREATMENT] for bruit and thrill. In addition, the care plan indicated the site would be monitored for signs/symptoms of complications. The policy for assessment of arteriovenous shunts, fistulas, and grafts was provided and reviewed on 04/14/14 at 1:30 p.m. It indicated staff would palpate for the presence of a thrill and auscultate for the presence of a bruit, with a minimum frequency of every twenty-four (24) hours. An interview with the director on nursing (DON) and the corporate consultant (Employee #181) on 04/14/14 at 3:00 p.m., revealed the facility had no additional policies regarding evaluation of a resident receiving [MEDICAL TREATMENT]. The DON said standard nursing practices were utilized. An interview with Employee #70, licensed practical nurse (LPN), on 04/14/14 at 2:45 p.m., revealed staff recorded information regarding the [MEDICAL TREATMENT] on the treatment administration record (TAR). She reviewed the TAR and confirmed no record of assessments and monitoring were present. The Medication Administration Record [REDACTED].m She related she was not aware of a specific assessment completed prior to, or upon return from [MEDICAL TREATMENT]. The RN reviewed the medical record and also confirmed no evidence was present to indicate staff were assessing and monitoring the fistula site daily. Further review of the medical record, on 04/14/14 at 11:29 a.m., revealed an order dated 04/06/14. It indicated the resident was to have a follow-up with the surgeon within seven (7) days. A transition chart record, dated 04/06/14, noted an impression of dependent [MEDICAL CONDITION], right arm and recent AV gortex fistula for [MEDICAL TREATMENT]. Follow up with Dr. ______ this week. Upon inquiry, Employee #74 reviewed the physician's orders [REDACTED]. She verified the resident did not go to the follow-up appointment. She reviewed the medical record and confirmed the order was not discontinued, nor was there information which indicated why he did not go as ordered. An interview with Employee #101, an RN and director of care delivery, on 04/15/14 at 8:30 a.m., confirmed there was no evidence the physician's orders [REDACTED]. | 2018-04-01 |
| 6296 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 323 | D | 0 | 1 | ZU6S11 | Based on record review, staff interview, review of the facility's documentation of incidents, review of in-service records, and an interview with a representative from the mechanical lift company, the facility failed to ensure the resident's environment was as free as possible from avoidable accidents. One (1) of three (3) residents reviewed for accidents in Stage 2 of the survey was lifted with an altered sling attached to a mechanical lift, resulting in a fall. In addition, there was no evidence of adequate training in the use of the mechanical lift to prevent avoidable accidents. Resident identifier: #30. Facility census: 105. Findings include: a) Resident #30 The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. When examined, a nurse noticed the resident's left leg was a different length than the right leg. The resident complained of pain in her leg, hip, and back when she was moved. The resident was transported to an acute care hospital. The hospital found no evidence of a fracture and there was no evidence the pain persisted. A review of the incident report for the date of 04/04/14 for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand in the Sara 3000 lift to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m., with Employee #159, a nursing assistant (NA). During the interview she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) arm under the sling, and fell to the floor. During the interview, Employee #159 was asked to explain the procedure for using the Sara 3000 lift. She stated they were to put the sling around the resident's mid-torso region and snap the buckles on the sling into place. She stated they then attached the clips from the sling to the attachment on the lift. Employee #159 stated there were no buckles on the sling to snap Resident #30 in place around the mid-torso region. She confirmed she knew she was supposed to snap the buckles to hold the resident in place. When asked if she had identified the buckles were missing while she was standing Resident #30, she stated she did not notice the buckles were missing from the sling. The NA stated she did not think Employee #33 knew either, because she did not say anything to her while they were attempting to use the Sara 3000 lift. An interview was conducted with Employee #16, the direct care delivery (DCD) nurse, on 04/09/14 at 2:00 p.m., regarding Resident #30's fall. She stated she was called to the room because the resident had slid out from under the sling while the NAs were attempting to stand up the resident. Employee #16 stated the resident complained of pain in her right hip and the physician was notified. She said the resident was transferred to an acute care hospital for evaluation. Employee #16 said the resident returned at a later time that day with a recommendation to follow up with a cat scan (CT) for the hip and her head. The DCD was asked what had caused the fall. She stated the buckles were cut off of the sling, so there was nothing to hold the resident in the Sara 3000 lift. The DCD was asked who trained the employees on the use of the Sara lift. She stated training was provided by the company from whom the facility purchased the lifts. The DCD stated upon hire, all nursing staff must watch a video on how to use the different types of lifts in the facility. She stated she did not know when the company may have been in to provide any training on how to use the Sara lift. The NA in-service records were reviewed on 04/09/14 at 2:00 p.m. The Sara lift in-services contained no evidence the NAs were evaluated for competency in the use of a Sara 3000 lift. The in-service records contained only signatures which represented the NAs had watched the videos. An interview was conducted, on 04/09/14 at 3:30 p.m., with three (3) NAs, Employees #30, #113, and #151. When asked what training they had on the use of the Sara 3000 lift, the NAs confirmed the only training they had was watching a video. On 04/09/13 at 2:50 p.m., the DON confirmed she was told about Resident #30's fall. She said she looked at the sling, then asked Employees #33 and #159 to tell her how the resident could have possibly fallen out of the sling with the mid-torso buckles in place. She stated when she said this, Employee #159's eyes got real big and Employee #159 walked away. She said Employee #159 returned with the sling and said to the DON, They aren't there. The DON stated she asked the employees, Did you have the buckles hooked to her middle torso? The DON said Employee #33, and #159 stated No. The DON asked the employees why they would you use a sling that did not have the buckles in place. The DON said Employee #159 stated she did not realize the buckles were not there. The DON said she immediately reviewed, with the NAs, the need to check the integrity of all slings prior to putting them around or underneath a resident. She also said she reviewed the proper use of the Sara lift with the NAs. The DON stated she then took the Sara lift and the altered sling, which was used with Resident #30, to the administrator's office and described the accident and the circumstances surrounding the accident to the administrator. An interview was conducted, on 04/09/14 at 3:38 p.m., with Employee #64, a registered nurse (RN). When asked how Resident #30 fell from the Sara 3000 lift, she stated the resident slid out of the lift. Employee #64 said an aide told her Resident #30 was lying on the floor. She said when she went to assess the resident, she observed Resident #30 lying on her back with her feet toward the window. The resident's assessment revealed she was having pain in her right hip. Employee #64 stated she called the physician, and the physician told her to send the resident to the emergency room for evaluation. Employee #64 said when her hip was touched, the resident said she was having pain. Employee #64 said she reported the fall to Employee #72, the director of nursing (DON). On 04/09/14 at 4:19 p.m., the administrator was interviewed. She stated after she was informed Resident #30 had fallen out of the Sara lift and the sling was altered, the facility did a house wide sweep to check the integrity of all slings on both units. One (1) additional sling used for the Sara lifts was found altered. The administrator said the sling was missing a portion of one (1) buckle. During an interview with the DON on 04/10/14 at 8:30 a.m., she confirmed the accident was a result of a failure to utilize the Sara lift sling appropriately on 04/04/14. A telephone interview was conducted on 04/11/14 at 7:32 a.m., with Employee #83, a licensed practical nurse (LPN). She was the nurse on duty when Resident #30 fell out of the Sara 3000 lift sling. When asked what occurred, the LPN stated Employee #64 told her Resident #30 was being lifted with a Sara 3000 lift, and the resident let go of the handles and fell . When asked if a resident would fall just by letting go of the handles, the LPN stated, If the sling had been fastened on her waist, she would not have fallen. On 04/11/14 at 11:30 a.m., a telephone interview was conducted with a representative from the mechanical lift company. He commented he had to replace the hand control module on the Sara lift because it would not raise the lift. When asked if the hand control module could have caused the resident to fall out of the lift, he stated, No, because you can manually raise and lower the lift. The representative stated he determined the resident fell because the mid-section buckles, used to hold the resident in place, were both cut off. He stated that without the two (2) buckles on the mid-section of the sling, there was nothing to hold the resident in place. | 2018-04-01 |
| 6297 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 325 | G | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for nutritional services, in a total sample of twenty-nine (29) Stage 2 residents, was provided services to maintain acceptable parameters of nutritional status, resulting in actual harm to the resident. The facility did not identify, assess, or address the resident's severe weight losses. In a forty-two (42) day period, the resident experienced three (3) weight losses of over 5% each. The weight losses were not recognized, assessed, or addressed by the facility until the resident had already experienced an overall weight loss of 15.64% in forty-two (42) days. Resident identifier: #147. Facility census: 105. Findings include: a) Resident #147 Review of Resident #147's medical record, on 04/10/14 at 9:00 a.m., revealed the resident was admitted on [DATE]. The admission weight was recorded as 104.8 pounds (lbs). The resident's five (5) recorded weights from 11/06/13 to 12/18/14 were as follows: 1. 11/06/13 = 104.8 2. 11/20/13 = 97.6 (loss of 6.87%) - The facility rounded this up to 98 for the minimum data set (MDS) 3. 11/27/13 = 92.2 (additional loss of 5.3%) 4. 12/04/13 = 94.2 (increase of 2.12%) 5. 12/18/13 = 88.4 (loss of 6.15%) The resident's minimum data set (MDS), with an assessment reference date (ARD) of 11/20/13, was reviewed on 04/10/14 at 9:17 a.m. Item K0300, indicating a weight loss of five (5) percent or more in the last month was coded Yes. It also noted the resident was not on a physician-prescribed weight-loss regimen. Review of the resident's care plan, on 04/10/14 at 9:22 a.m., revealed Resident #147 had no care plan related to weight loss until 02/13/14. The resident experienced a significant weight loss between 11/06/13 and 11/20/13, and again between 12/04/13 and 12/18/13. An interview was conducted with Resident #147 on 04/10/14 at 9:49 a.m. She said when she first came to the facility, she could not eat the food because it was too sweet. She said she had pancakes that morning and could not eat them because the syrup was too sweet. When asked if she had discussed this with the dietary department, she stated they had been told the food was too sweet for her liking. The registered dietitian's (RD), Employee #178, progress notes were reviewed on 04/14/14 at 11:00 am. The first RD note was dated 11/07/13. There were no other nutritional notes in the medical record, until the next RD notes dated 12/18/13. There was no documentation in the resident's medical record by Employee #180, the food service director/general manager. The RD's note on 11/07/13 stated the resident was within her ideal body weight, and had no [MEDICAL CONDITION]. The RD wrote, Wt (weight) fluctuation possible with res (resident) recently [MEDICATION NAME] and on [MEDICATION NAME]. The RD noted the resident was to be weighed weekly for four (4) weeks. No nutritional interventions were necessary and/or recommended at that time. Review of the RD's documentation dated 12/18/13, revealed the first evidence the RD had identified and addressed the resident's weight loss. The RD noted a conversation with the resident's son, who reported his mother was not eating and disliked the food. The RD made recommendations for vanilla nutrition shakes twice a day and vanilla ice cream for weight loss. This was the first nutritional intervention recommended for the resident's weight loss. By 12/18/13, the resident had experienced two (2) significant weight losses (5% or more) and had an overall loss of 16.4 lbs (15.64%) between 11/06/13 and 12/18 13, representing a severe weight loss. An interview was conducted on 04/15/14 at 9:07 a.m. with the RD. She stated the resident was [MEDICATION NAME] while in the hospital, prior to coming to the facility. Upon inquiry, the RD stated she had not recommended a supplement/intervention because the resident was placed on [MEDICATION NAME], a medication for anxiety, that would help with improving her appetite. When asked if anyone from the facility notified her Resident #147 was losing weight, she said they had not. She confirmed she was not aware of the weight loss until 12/18/13. Review of the medical record, on 04/15/14 at 9:20 a.m., revealed on 11/19/13, Resident #147 was ordered [MEDICATION NAME] 0.5 mg as needed (PRN) every six (6) hours for anxiety. She was given the PRN [MEDICATION NAME] only once in November 2013, on 11/19/13. She was not given the [MEDICATION NAME] during the month of December 2013. An interview was conducted with Employee #180, the food service director/general manager on 04/15/14 at 9:10 a.m. She stated she reviewed Resident #147's weight loss during their department head morning meeting, where they document everything that was discussed in the meeting. Employee #180 said she would review the notes and provide a copy of the note where she had discussed Resident #147's weight loss. Later, Employee #180 returned and stated she could not find any evidence Resident #147's weight loss was discussed during the department head morning meetings. When asked if she had identified Resident #147 was having weight loss, and what nutritional interventions were put in place for the severe weight loss, Employee #180 made no comment. During an interview and review of the weights for Resident #147, with the director of nursing (DON) on 04/15/14 at 11:15 a.m., she said the scales may have been inaccurate, but that she was not aware of a problem so she did not have the scales checked for inaccurate weighing. She confirmed Resident #147 was not re-weighed after weight losses were indicated on the weights and vital summary sheet. The DON said facility procedure was for the nursing assistant to weigh the resident and report the weight to the nurse. The nurse was responsible for documenting the weight in the computer. The DON said the nurse on duty the day the weights were obtained was responsible for reviewing the weights. If a weight loss had occurred, the nurse was responsible for informing the physician and the food service director/general manager. She stated if a resident had a weight loss, the nurses were also to put the resident on a critical alert form. The DON stated she reviewed the critical alert forms, and there was no evidence staff placed Resident #147 on the critical alert form for weight loss. She also confirmed she had no evidence the weight loss was reported to the physician and food service director/general manager as required. On 04/15/14 at 11:50 a.m., an interview was conducted with Employee #142, the MDS coordinator. She was asked about the completion of the 11/20/13 MDS and section K0300 for Resident #147, related to a weight loss of five (5) percent in the last month or a loss of ten (10) percent or more in last six (6) months. Employee #142 said she looked at the weights seven (7) days back to determine the weight for the MDS. She stated she rounded the weights up or down. For instance, Resident #147's weight was 97.6 lbs, so she rounded it up to 98. When asked if she notified other staff members about weight losses she found while doing MDSs, she stated she discussed them during the stand-up meetings. Employee #142 said she had tried to find the information to prove she had brought this to the department head meeting, but she could not find evidence she had discussed the resident's weight losses with anyone. An interview was conducted on 04/15/14 at 12:20 p.m., with Employees #62 (administrator), #178 (dietitian), #179 (dietitian),#101 (director of care delivery), and #72 (director of nursing.) When asked if they identified Resident #147 had a severe weight loss, the DON stated they believed the weights were not accurate; however, she had no evidence to provide to indicate the weights were inaccurate. During this interview, Employee #101 stated the resident had anxiety, was medicated with [MEDICATION NAME], and this medication had helped to improve her appetite. The DON stated they reviewed information about Resident #147 having weight loss in the department head meeting, but she confirmed she could not find any evidence in the meeting minutes about Resident #147 and her weight loss. When the above staff members were asked what interventions they implemented to prevent further weight loss, no one commented. An additional review of the medical record, on 04/15/14 at 12:30 p.m., after the interview on 04/15/14 at 12:20 p.m., revealed no evidence any employee had identified, assessed, and/or addressed the resident's weight loss until 12/18/13. The resident's weight records indicated a 6.87% (severe) loss between 11/06/13 and 11/20/13. Between 11/20/13 and 11/27/13, the resident's weight records indicated another severe weight loss of 5.3%. By 12/18/13, when the RD became aware the resident's records indicated a weight loss, all evidence suggested the resident had lost 15.64% of her total body weight between 11/06/13 and 12/18/13. Even if the weights were inaccurate, as suggested by the DON, the resident's weight records indicated weight losses which the facility failed to identify and assess to determine accuracy and/or to determine if interventions were necessary. In addition, although the resident had an order for [REDACTED].#101. As well, the DON stated they had reviewed information about Resident #147 having weight loss in department head meetings. When asked to see that evidence, staff confirmed they could not find evidence of discussions of this resident's weight losses in the department head meeting minutes. An interview on 04/15/14 at 1:00 p.m., with Employee #179 (dietitian), and Employee #72 (DON) confirmed the facility had no evidence they identified, reported, assessed, or provided nutritional interventions related to Resident #147's weight loss. | 2018-04-01 |
| 6298 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 456 | D | 0 | 1 | ZU6S11 | Based on record review, review of the facility's documentation or incidents, staff interview, and an interview with a representative from the mechanical lift company, the facility failed to ensure resident care equipment was maintained in a safe and operating condition. One (1) of three (3) residents reviewed for accidents had a fall due to faulty equipment. Resident identifier: #30. Facility census: 105. Findings include: The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. A review of the incident report for the date of 04/04/14 for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand in the Sara 3000 lift to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m., with Employee #159, a nursing assistant (NA). During the interview she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) arm under the sling, and fell on to the floor. During the interview, Employee #159 was asked to explain the procedure for using the Sara 3000 lift. She stated they were to put the sling around the resident's mid-torso region and snap the buckles on the sling into place. She stated they then attached the clips from the sling to the attachment on the lift. Employee #159 stated there were no buckles on the sling to snap Resident #30 in place around the mid-torso region. She confirmed she knew she was supposed to snap the buckles to hold the resident in place. An interview was conducted with Employee #16, the direct care delivery (DCD) nurse, on 04/09/14 at 2:00 p.m., regarding Resident #30's fall. She stated she was called to the room because the resident had slid out from under the sling while the NAs were attempting to stand up the resident. The DCD was asked what had caused the fall. She stated the buckles were cut off of the sling, so there was nothing to hold the resident in the Sara 3000 lift. On 04/09/13 at 2:50 p.m., the DON confirmed she was told about Resident #30's fall. She said she looked at the sling, then asked Employees #33 and #159 to tell her how the resident could have possibly fallen out of the sling with the mid-torso buckles in place. She stated when she said this, Employee #159's eyes got real big and Employee #159 walked away. She said Employee #159 returned with the sling and said to the DON, They aren't there. The DON stated she asked the employees, Did you have the buckles hooked to her middle torso? The DON said Employee #33, and #159 stated No. The DON asked the employees why they would you use a sling that did not have the buckles in place. The DON said Employee #159 stated she did not realize the buckles were not there. On 04/09/14 at 4:19 p.m., the administrator was interviewed. She stated after she was informed Resident #30 had fallen out of the Sara lift and the sling was altered, the facility did a house wide sweep to check the integrity of all slings on both units. One (1) additional sling used for the Sara lift was found altered. The administrator said it was missing a portion of one (1) buckle. On 04/11/14 at 11:30 a.m., a telephone interview was conducted with a representative from the mechanical lift company. He commented he had to replace the hand control module on the Sara lift because it would not raise the lift. When asked if the hand control module could have caused the resident to fall out of the lift, he stated, No, because you can manually raise and lower the lift. The representative stated he determined the resident fell because the mid-section buckles, used to hold the resident in place, were both cut off. He stated that without the two (2) buckles on the mid-section of the sling, there was nothing to hold the resident in place. | 2018-04-01 |
| 6299 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 465 | D | 0 | 1 | ZU6S11 | Based on observation, resident interview, and staff interview, the facility failed to provide a comfortable environment for one (1) of twenty-nine (29) residents reviewed during Stage 2 of the Quality Indicator Survey. The heater was not functioning correctly in Resident #120's bathroom. Facility census: 105. Findings include: a) Resident #120 An interview was conducted on 04/10/14 at 10:10 a.m. with Resident #120. During this Stage 1 interview, the resident stated his room was cold when staff left the bathroom door open. He said leaving the bathroom door open created a draft, causing his bedroom to be cold. An observation of Resident #120's room was conducted with the maintenance director, Employee #124, on 04/10/14 at 10:30 a.m. When the situation was discussed, Employee #124 stated if the resident was cold, the resident could just turn the heater on in the bathroom. When he first entered the bathroom, the maintenance director commented the bathroom temperature was a little bit cooler than the bedroom temperature. Employee #124 checked the air temperature in the bathroom. It was 66.5 degrees Fahrenheit. He then attempted to turn on the heater in the bathroom, but the heater would not function. Employee #124 stated to the resident, I will have the heater fixed. | 2018-04-01 |
| 6300 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 492 | C | 0 | 1 | ZU6S11 | Based on staff interview, facility record review, and interview with personnel from the local county health department, the facility failed to operate in compliance with state and local laws, regulations, and codes that apply to professionals providing services. The facility failed to ensure a dietary aide had a food handler's card. The county in which the facility was located required food handler's cards for food service personnel. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 105 Findings include: a) During a review of food handler's cards, on 04/08/14 at 3:30 p.m., no evidence of a card was present for Employee #176, a dietary aide. The food service director was interviewed at 3:45 p.m. She verified the dietary aide did not have a food handler's card. She said the employee had only worked about a month. An inquiry with the local county health department, on 04/09/14 at 8:00 a.m., confirmed a food handler's card was required for food service personnel in the county. Another interview with Employee #181, on 04/09/14 at 9:00 a.m., again confirmed the facility had not complied with the state and local laws requiring a food handler's card. | 2018-04-01 |
| 6301 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 498 | D | 0 | 1 | ZU6S11 | Based on record review, review of the facility's documentation of incidents, staff interview, review of the Sara 3000 lift manufacturer's manual, and interview with a representative from the mechanical lift company, the facility failed to ensure nursing assistants (NAs) were competent in the skills and techniques necessary to care for residents. NAs used a Sara 3000 lift with an altered sling, resulting in a fall for one (1) of three (3) residents reviewed for accidents during Stage 2 of the survey. There was no evidence nursing personnel were adequately trained and/or evaluated for competency in using the Sara 3000 lift. Resident identifier: #30. Facility census: 105. Findings include: a) Resident #30 The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. A review of the incident report, for the date of 04/04/14, for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand with the Sara 3000 lift to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m., with Employee #159, a nursing assistant (NA). During the interview she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) arm under the sling, and fell to the floor. Employee #159, NA, was asked to explain the procedure for using the Sara 3000 lift. She stated they were to put the sling around the resident's mid-torso region and snap the buckles on the sling into place. She stated they then attached the clips from the sling to the attachment on the lift. During the interview at 1:45 p.m. on 04/09/14, Employee #159 stated there were no buckles on the sling to snap Resident #30 in place around the mid-torso region. She confirmed she knew she was supposed to snap the buckles to hold the resident in place. When asked if she had identified the buckles were missing while she was standing Resident #30, she stated she did not notice the buckles were missing from the sling. The NA stated she did not think Employee #33 knew either, because she did not say anything to her while they were attempting to use the Sara 3000 lift. Review of the Sara 3000 lift manufacturer's manual on 04/09/14 at 1:50 p.m., revealed it described the proper procedure on how to use the Sara 3000 sling and lift. The book also had a picture that demonstrated how to place the sling around the mid-torso. Under the picture, there was a statement instructing the user to press the buckles on the sling together. An interview was conducted, on 04/09/14 at 1:55 p.m., with Employee #157, the human resource director (HRD). She was asked for competency verification for the use of the Sara 3000 lift for Employees #33 and #159. -- Employee #157 provided Employees #33's general orientation program check list. This list was checked off only by the employee. There was no evidence Employee #33 was evaluated by supervisory or other appropriate personnel for competency in the use of the Sara 3000 lift, or any of the areas noted on the check list. -- Employee #157 provided the in-service records for Employee #159 for 2004, 2005, 2007, and 2008. There were no in-service records for 2006 or any year since 2008. The checklists provided were checked off only by the employee. There was no evidence Employee #159 was evaluated by supervisory or other appropriate personnel for competency in the use of the Sara 3000 lift, or any of the areas noted on the check list. When Employee #157 was asked if she had any other records which might show the NAs were deemed competent in using the Sara 3000 lift, she said she had provided everything she had. Nursing assistant in-service records were reviewed on 04/09/14 at 2:00 p.m. The Sara lift 3000 in-services contained no evidence any NAs were evaluated for competency in the use of a Sara 3000 lift. The in-service records contained only signatures which represented the NAs had watched the video. An interview was conducted with Employee #16, the direct care delivery (DCD) nurse, on 04/09/14 at 2:00 p.m., regarding Resident #30's fall. She stated she was called to the room because the resident had slid out from under the sling while the NAs were attempting to stand up the resident. The DCD was asked what had caused the fall. She stated the buckles were cut off the sling, so there was nothing to hold the resident in the Sara 3000 lift. The DCD was asked who trained the employees on the use of the Sara lift. She stated training was provided by the company from whom the facility purchased the lifts. The DCD stated she did not know when company personnel had last come to the facility to provide training on how to use the lift. She stated upon hire, all nursing staff must watch a video on how to use the different types of lifts in the facility. When asked if anyone observed staff members for competency in using the Sara 3000 lift after they watched the video, the DCD said they did not. She said the employees just had to sign they watched the video. On 04/09/13 at 2:50 p.m., the DON confirmed she was told about Resident #30's fall. She said she looked at the sling, then asked Employees #33 and #159 to tell her how the resident could have possibly fallen out of the sling with the mid-torso buckles in place. She stated when she said this, Employee #159's eyes got real big and Employee #159 walked away. She said Employee #159 returned with the sling and said to the DON, They aren't there. The DON stated she asked the employees, Did you have the buckles hooked to her middle torso? The DON said Employee #33, and #159 stated No. The DON asked the employees why they would you use a sling that did not have the buckles in place. The DON said Employee #159 stated she did not realize the buckles were not there. The DON said she immediately reviewed, with the NAs, the need to check the integrity of all slings prior to putting them around or underneath a resident. She also said she reviewed the proper use of the Sara lift with the NAs. An interview was conducted with three NAs, Employees #40, #113, and #151, on 04/09/14 at 3:30 p.m. When asked what training they received related to the use of the 3000 lift, they confirmed they only watched a video. When asked if anyone observed them use the lift to demonstrate competency on the use of the Sara 3000 lift, they said this had not occurred. The NAs said sometimes a representative from the company from whom the lift was purchased had come to the facility to provide an in-service; however, they could not recall when this last occurred. An telephone interview was conducted, on 04/17/14 at 11:12 a.m., with a representative from the company from whom the facility purchased the Sara 3000 lift. He was asked if the company provided training and observed for competency in the use of the Sara 3000 lift. The representative said, We do not in-service and check off every staff member at each facility on the use of equipment. It is not required and that would be virtually impossible as staff come and go. The representative said the company offered a very extensive transfer mobility coach (TMC) training class, at no charge, to their customers. He stated it was based on a proven model of Train the Trainer. The representative stated by training specifically chosen caregivers as TMCs, with enhanced training of the equipment and sling placement/inspection, those TMCs can train their nursing units, working one-on-one to instruct staff in the proper techniques of the equipment and sling placement/inspection. The representative was asked whether anyone was trained as a TMC at the facility. He stated they usually were, but he did not know about this particular facility. . | 2018-04-01 |
| 6302 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 272 | D | 0 | 1 | WS1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident observation, the facility failed to assess a resident's wounds to identify the underlying cause of his skin condition. This resulted in the resident's significant change assessment being coded incorrectly. One (1) of seventeen (17) Stage 2 sample residents reviewed for accuracy of the comprehensive assessment was affected. Resident identifier: #21. Facility census: 54. Findings include: a) Resident #21 Review of this resident's medical record, on 02/27/14, found his significant change minimum data set (MDS), with an assessment reference date (ARD) of 01/02/14, Item M0300F indicated the resident had three (3) unstageable pressure ulcers present upon entry to the facility. Item M1030 - Number of Venous and Arterial Ulcers, indicated the resident had no venous or arterial ulcers. Section I, Active Diagnoses, Item I0900 indicated the resident had peripheral vascular or [MEDICAL CONDITION]. (The physician's list of [DIAGNOSES REDACTED].) An observation of the resident's wounds, with Employee #5, a registered nurse, at 10:00 a.m. on 02/27/14, revealed the resident had four (4) ischemic ulcers on the toes of his left foot. (One (1) of these ulcers had not been present at the time the significant change MDS was completed.) In an interview with the Director of Nursing, at 11:12 a.m. on 02/27/14, she agreed Resident #21's wounds were vascular (arterial or venous), not pressure ulcers and the MDS had not been coded accurately. | 2018-04-01 |
| 6303 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 280 | D | 0 | 1 | WS1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise Resident #21's care plan in the regards to the development of skin issues. The resident's care plan was not revised to address actual problems with skin integrity. This was true for one (1) of seventeen (17) Stage 2 sample residents. Resident identifier: #21. Facility Census: 54. Findings include: a) Resident #21 This resident was readmitted to the facility on [DATE]. His admission nursing assessment noted he had unstageable pressure ulcers to left 3rd and 4th digits with intact scabs and unstageable pressure ulcer to right 2nd digit with intact scabs His significant change minimum data set (MDS), with an assessment reference date (ARD) of 01/02/14, indicated the resident had three (3) unstageable pressure ulcers present upon entry to the facility in Item M0300F. Medical record review found a current physician's orders [REDACTED]. Observation performed during Stage 2 at 10:00 A.M. on 02/27/14 found he had black circles on top of left 2nd, 3rd and 4th toe and the right foot 3rd toe. Review of the current care plan found no mention of the ulcers, just that he had a history of [REDACTED]. During an interview with the Director of Nursing, on 12/27/14 at 11:12 a.m., she agreed the care plan about the resident's skin condition had not been revised and the ulcers were not addressed in the current care plan. | 2018-04-01 |
| 6304 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 309 | D | 0 | 1 | WS1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's quick reference guidelines, and staff interview, the facility failed to provide care and services necessary to meet the needs of the resident in the order to maintain the highest practicable well-being. The facility failed to accurately assess three (3) vascular ulcers and to identify signs and symptoms of wound infection. There was also a failure to recognize presence of a fourth wound. The facility also failed develop a care plan to address all four (4) wounds present. One (1) of three (3) residents reviewed with pressure ulcers was affected. Resident identifier: #21. Facility census: 54. Findings include: a) Resident #21 When Resident #21 was admitted to the facility on [DATE], his admission assessment stated he had three (3) unstageable ulcers on his toes. Specifically, one on his left 3rd toe, one on his left 4th toe, and on his right foot he had one on his right 2nd toe. A significant change minimum data (MDS) set assessment, with an assessment reference date (ARD) of 01/02/14, identified the resident had three (3) unstageable pressure ulcers present upon entry to the facility. The Wound and skin care procedures quick reference guidelines - physician order [REDACTED]. Review of the physician's diagnosis list found the list included [MEDICAL CONDITION] as a diagnosis, but there was nothing identified about the ulcers on the resident ' s foot. The current care plan described history of ulcers, but did not describe the current ulcers. A review of the treatment sheet for 02/26/14, found the night nurse had not completed a weekly skin assessment 02/26/14. The next morning, on 02/27/14 at 10:00 a.m., the resident's feet were observed with Employee #5, a Registered Nurse. The resident had a total of four (4) ulcers. The facility was unaware of one (1) of the four (4) ulcers. There was no evidence an area on his left 2nd toe had been identified prior to this observation. The ulcer on the left 3rd toe had signs of infection. The scab of this wound was coming loose and his foot was reddened from his toes extending midway on the top of the foot. After the observation, the RN notified the physician and received orders for a topical treatment and antibiotic therapy. In an interview with the Director of Nursing, on 02/27/14 at 11:12 a.m., she agreed it was problematic that the type of wound was improperly assessed, there was no [DIAGNOSES REDACTED]. | 2018-04-01 |
| 6305 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 356 | B | 0 | 1 | WS1J11 | Based on observation, staff interview, and review of staff postings, it was determined the facility failed to post the required nurse staffing data in a prominent place in the facility that was readily accessible to residents and visitors. This had the potential to affect more than a limited number. Facility census: 54. Findings include: a) An attempt to locate the required nurse staffing data posting during the initial tour of the facility on 02/24/14 at 12:30 p.m., revealed it was not posted. During an interview with the director of nursing (DON), Employee #12, on 02/24/14 at 12:37 p.m., she verified there was no posting of the current staffing data in the facility. On 02/26/14 at 4:30 p.m., the staffing sheet was found on a clip board at the nurses' desk with the day shift posting only. Registered Nurse (RN), Employee #4, verified the staff posting was not completed for evening shift and stated she would inform the DON. The staffing was posted for the evening shift at 4:50 p.m. | 2018-04-01 |
| 6306 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 492 | F | 0 | 1 | WS1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each dietary employee had a valid food handler's permit as required by county regulations. Two (2) dietary employees did not have current food handler's cards. This had the potential to affect all residents who received nourishment from the dietary department. Facility census: 54. Findings include: a) Upon entrance, facility personnel were asked to provide evidence of food handler's permits, if the county in which the facility was located required them. On [DATE] at 11:00 a.m., a review of the food handler's permits, with the food service director (Employee #11), revealed Employees #2 and #65, cooks, did not have valid food handler's permits. Employee #65's card had expired in [DATE], and Employee #2's card had expired in [DATE]. A review of the food service schedules for [DATE] through February 2014, verified Employees #2 and #65 had been working with expired food permits. During a telephone interview on [DATE] at 2:00 p.m., Employee #79, of the county health department, confirmed dietary employees were required to maintain current food handler's permits. | 2018-04-01 |
| 6307 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 157 | E | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the family and/or responsible party of changes in condition in a timely manner for one (1) of ten (10) residents reviewed during a complaint survey ending on 04/28/15. There was no evidence Resident #87's family and/or responsible party was notified on multiple occasions when the resident had medication and diet changes, weight loss, and injuries of unknown origin. Resident identifier: #87. Facility census: 86. Findings include: a) Resident #87 Review of Resident #87's medical record, on 04/22/15 at 1:00 p.m., revealed the resident was admitted to the facility on [DATE] at 2:40 p.m. This ninety-one year old female had [DIAGNOSES REDACTED]. Further review of medical records, on 04/23/15, found a Brief Interview for Mental Status (BIMS) completed on 01/28/15. The BIMS score was eight (8). This score indicated a moderately impaired cognitive status. The resident's medical record indicated her son was appointed the Medical Power of Attorney (MPOA). Review of the medical records found no evidence Resident #87's MPOA was notified of the following changes in the resident's medication and diet, weight loss, and injury of unknown origin: - 01/26/15 at 2:40 p.m. - An order noted on admission for [MEDICATION NAME] 5/325 milligrams (mg) by mouth (po); give 0.5 (1/2) tablet every eight (8) hours as needed (prn). On 01/27/15 at 7:49 a.m., a clarification order for [MEDICATION NAME] 5/325 mg every 8 hours as needed for pain. Previous order for 1/2 tablet of [MEDICATION NAME] (2.5 mg) was discontinued. - 01/28/15 at 12:00 p.m. - The resident was seen by the Physician Assistant (PA). The PA's progress note read, . Patient seen today for lethargy . She was started on [MEDICATION NAME] 5/325 mg yesterday and today nursing noted this change and wanted her evaluated. She reports no pain complaints and is difficult to arouse but will speak. Assessment /Plan and Other information: 1) Lethargy: likely related to narcotic will hold today and cut dose to 2.5 mg one tablet po three times a day (tid) prn. Will monitor and discussed this with charge nurse. - 02/01/15 at 1:16 p.m. - The resident had three (3) loose, foul smelling stools. Physician was notified of the loose stool. New orders were obtained to stop [MEDICATION NAME] and obtain a stool sample for [MEDICAL CONDITIONS] to rule out [MEDICAL CONDITIONS]. - 02/04/15 - A new order was added for house supplement three (3) times daily with snacks - 02/11/15 at 2:37 - An order was written to decrease [MEDICATION NAME] to 0.5 mg by mouth (po) tid (three times a day). - 02/13/15 - The resident was seen by the psychiatrist in the facility. New orders were written to increase [MEDICATION NAME] to 20 mg po daily in the morning and increase [MEDICATION NAME] (antidepressant) to 30 mg po daily at night. - 02/22/15 at 10:34 a.m. - The resident was on [MEDICATION NAME] for pneumonia. The laboratory notified the facility of critical lab results. The urine culture showed bacteria that produced enzymes called extended-spectrum beta-lactamases (ESBLs). These are resistant to many [MEDICATION NAME] and cephalosporin antibiotics as well as other types of antibiotics. The white blood count (WBC) was 17.5 (normal value is 3.3 - 8.7). A Brain Natriuretic Peptide (BNP) Test result was 1433. BNP levels above 900 indicate severe heart failure. - 02/23/15 - New orders were written to discontinue [MEDICATION NAME] (antibiotic) and start [MEDICATION NAME] (antibiotic) 100 mg po twice daily for seven (7) days for treatment of [REDACTED]. - 03/06/15 - The physician was in the facility to examine the resident. New orders were written to change accuchecks to two (2) hours after the meal one (1) time daily and to use the standard sliding scale coverage. The order also indicated to repeat the hemoglobin A1c (HgbA1C) test, for [DIAGNOSES REDACTED]. - 03/09/15 at 2:40 p.m. - The PA was in the facility to examine the resident. A new order was written to obtain a Chest X-ray due to resident coughing. - 03/09/15 at 11:18 a.m. - Weight warning. Value: 87.8 pounds (#) obtained on 03/02/15 at 3:00 p.m. Minimum Data Set (MDS): loss of 5% change over thirty (30) days (9.5% or 9.2#) Loss of 7.5% change (9.5% or 9.2 #). Residents weight is the same as previous evaluation at 87#. Resident's appetite is fair with assistance from staff - 03/13/15 - The resident was seen by the psychiatrist in the facility. New orders were written to start [MEDICATION NAME] 5 mg po every night. - 03/18/15 at 11:00 a.m. - New orders from the Speech Therapist were written to discontinue nectar thickened liquids and to start honey thickened liquids. - 03/21/15 at 5:57 p.m. - The resident was screaming and indicated she was having pain in her right upper quadrant. The nurse's evaluation revealed the resident had a knot located underneath her rib cage on the right side. She was sent to the emergency room (ER). The resident returned to the facility at 11:35 p.m. Documentation from the ER physician indicated Resident #87's chief complaint was right rib pain. The discharge [DIAGNOSES REDACTED]. Instructions for the treatment of [REDACTED]. The MPOA was not notified of the hospital's findings On 04/24/15 at 10:30 a.m., the medical record was reviewed with the Director of Nursing (DON) related to the changes in Resident #87's condition. The DON verified the facility had no evidence the MPOA was notified of any of the changes in Resident #87's condition. | 2018-04-01 |
| 6308 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 225 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's reported allegations to state authorities, staff interview, resident interview, review of grievance/concern forms, and medical record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported to the proper state authorities and/or failed to ensure each situation was identified and thoroughly investigated for two (2) of ten (10) sample residents. One (1) of two (2) resident's (Resident #72) grievances related to an allegation of verbal and physical abuse was not identified, reported, or investigated. In addition, the facility failed to identify and investigate an injury of unknown origin for Resident #87, to rule out neglect or abuse. Resident identifiers: #72 and #87. Facility census: 86. Findings include: a) Resident #72 On 04/22/15 at 1:00 p.m., review of the grievance/concern forms found Resident #72 voiced a grievance with the facility's social worker on 03/04/15. The grievance was (typed as written): Resident concerned about missing leg tx.'s (treatments) not being done. She also has concerns about staff she says they have been talking behind her back-yelling (symbol for at) her because she comes to the desk to get her cigarettes early and taking up space. She alleges that the staff complains about taking her outside because she is so heavy-they don't want to push her. The social worker (SW) signed the form as completed on 03/06/15. The SW noted the resident's grievance was discussed with the assistant director of nursing. Further review of the facility's grievance/concern form revealed staff were required to describe the actions taken to investigate the grievance/concern. It also directed staff to identify the method used to notify the resident of the resolution. This information was not completed on Resident #72's form. At 4:15 p.m. on 04/22/15, the SW stated she discussed the situation with the director of nursing and the assistant director of nursing. She stated she talked to the resident, but had no evidence of the conversation. The SW was also unable to provide evidence an investigation was conducted. Upon inquiry, she confirmed Resident #72's allegations were not reported to the proper state authorities, as required by law, when a resident alleges neglect and verbal abuse. On 04/27/15 at 10:00 a.m., the administrator stated he reported the resident's allegations, made on 03/14/15, to the proper state authorities on 04/23/15. He provided a copy of his report. Review of the information provided by the administrator found a nursing assistant (NA) was reported to the nurse aide registry for allegedly talking about the resident. The allegation indicated the NA stated the resident was too heavy to assist outside to smoke. The administrator also reported, as a result of his investigation into the 03/04/15 grievance/concern, a registered nurse for being rude to the resident. Further review of the resident's nursing notes, on 04/22/15, found a nursing note, written on 02/13/15 at 6:58 p.m.: . Res. (resident) needed a lot of assistance this day helping her go to the BR (bathroom) on the commode. Linens changed several times, from res. voiding in the bed. Very emotional, feelings are hurt very easily. Res. felt that she was misunderstood during her first night here by the staff d/t (due to) her incont. (incontinence) of urine. She says she goes through this everywhere she's admitted . Rude remarks, jerking on her arms/legs, etc. She spoke to the DON (director of nursing) and Social Worker re: (regarding) the incident. During an interview at 4:30 p.m. on 04/22/15, the SW and DON stated they were unaware of the nursing note. Both employees denied any knowledge of the resident's allegations. At 10:00 on 04/27/15, the administrator provided verification the incident found in the 02/13/15 nurse's note was investigated and reported to the proper state authorities on 04/23/15. b) Resident #87 Review of Resident #87's medical record, on 04/22/15 at 1:00 p.m., revealed the resident was admitted to the facility on [DATE] at 2:40 p.m. A nurse's progress note, dated 03/21/15 at 5:57 p.m. read . Resident was screaming and indicated she was having pain in her right upper quadrant. The nurse's evaluation revealed the resident had a knot located underneath her rib cage on the right side. She was sent to the emergency room (ER). The resident returned to the facility at 11:35 p.m. with documentation from the ER physician. It indicated Resident #87's chief complaint was right rib pain. The discharge [DIAGNOSES REDACTED]. Instructions for the treatment of [REDACTED]. The medical records contained no indication the knot underneath the rib cage, potentially an injury of unknown origin, was investigated. On 04/24/15 at 10:30 a.m., the medical record was reviewed with the Director of Nursing (DON). The DON verified the facility was unable to provide evidence the injury of unknown origin was investigated. | 2018-04-01 |
| 6309 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 241 | D | 1 | 0 | J5M711 | Based on record review, observation, resident interview, and staff interview, the facility failed to provide an environment and promote care to maintain or enhance the dignity and respect for one (1) of five (5) residents reviewed and for one (1) resident found during a random opportunity for observation. For Resident #72, the facility failed to ensure staff spoke to her in a respectful manner. For Resident #46, the facility failed to keep a urinary catheter bag covered. Resident identifiers: #72 and #46. Facility census: 86. Findings include: a) Resident #72 On 04/22/15 at 1:00 p.m., review of the grievance/concern forms found Resident #72 filed a grievance with the facility's social worker (SW) on 03/04/15. Documentation on the grievance/concern included, . She also has concerns about staff - she says they have been talking behind her back-yelling @ (at) her because she comes to the desk to get her cigarettes early and taking up space. She alleges that the staff complain about taking her outside because she is so heavy - they don't want to push her. At 4:15 p.m. on 04/22/15, the SW confirmed she could not provide verification the resident's concerns on 03/04/15 were investigated. At 4:45 p.m. on 04/22/15, Resident #72 was asked if staff treated her with dignity and respect. She replied, No, they talk about me. She reported staff talked about her behind her back. Further review of the medical record found a nursing note, dated 02/13/15 at 6:58 p.m., which indicated the resident stated staff were making rude remarks to her. These remarks were supposedly made on the resident's night of admission, 02/12/15. There was no evidence the facility explored what rude comments were made. On 04/27/15 at 10:00 a.m., the administrator confirmed the concerns voiced by the resident on 02/13/15 were not investigated at that time. He stated they were investigated on 04/23/15, and provided copies of the investigation. The investigation was not conducted until the situation was brought to the attention of the facility during the survey. Information provided by the administrator included an interview with the resident, on 04/23/14, regarding the allegations of rude remarks made to the resident on her first night at the facility, 02/12/15. The interview with the resident revealed Employee #19 made the statement, We are going to have to cath. (catheterize) you. We can't come back in here every 15 minutes. On 04/23/15, the administrator spoke to the nursing assistant (NA) #19, who provided care to the resident on 02/12/14. A statement obtained from Employee #19 found, I did not say that to be mean about it. It was a concern about her . Further review of the investigation found Employee #19 received verbal counseling on 04/23/15 regarding her remarks to Resident #79. According to information in the investigation, the employee who supposedly made the comments to Resident #72 about her being too heavy to push outside to smoke no longer worked at the facility. The employee's statement could not be obtained. b) Resident #46 Resident #46 was observed, on 04/22/15 at 11:10 a.m., during the initial tour of the facility. The resident was resting in bed. Observation revealed the resident's urinary catheter drainage bag was not covered and was visible from the hallway . Review of the resident's care plan was conducted on 04/22/15 at 12:10 p.m. The care plan stated the resident's urinary catheter drainage bag was to be covered at all times. Interview with Employee #52, a registered nurse (RN), was conducted at 11:12 a.m. on 04/22/15. During that interview, Employee #52 agreed the catheter bag was not covered, was visible from the hallway, and should be covered. The RN was unable to locate a catheter bag cover in the resident's room. | 2018-04-01 |
| 6310 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 246 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, staff interview, and review of the medical record, the facility failed to ensure reasonable accommodations were provided in a timely manner, based on individual needs. The facility delayed addressing Resident #72's concerns regarding her inability to sleep on her mattress. This was true for one (1) of five (5) residents reviewed for accommodation of needs. Resident identifier: #72. Facility census: 86. Findings include: a) Resident #72 At 2:30 p.m. on 04/23/15, the resident stated she was unable to sleep in her bed when she first entered the facility in February 2015. She stated the mattress was too hard and it caused her hip to hurt. She said she made numerous complaints to staff,but nothing was done until about two (2) weeks ago when they finally gave her a new mattress. The resident said the new mattress was wonderful and she was now able to sleep in her bed every night. She said it was a shame she had to sleep sitting up in her wheelchair for two (2) months before the facility listened to her. Review of the resident's care plan found a problem, dated 02/15/15, Resident is at risk for skin breakdown as evidenced by limited mobility, de-conditioning, refuses to get out of her wheelchair and into bed. An intervention associated with this problem was, Resident refuses to sleep in her bed, refuses to take showers. Review of the nursing notes found the following entries: -- 03/10/15 at 7:19 a.m., Resident up in wheelchair sleeping all night, feet down on floor. -- 03/29/15 at 8:46 p.m., (typed as written), Resident continues to sleep in her wheelchair, refused to sleep in her bed at night, risks and complications explained without success, per resident she has sleep in her wheelchair since she has been here except for a couple of nights. She request a air mattress . -- 03/30/15 8:26 p.m., . Resident is obese and refuses to take showers or baths; she sleeps in her wheelchair and never in her bed . -- 04/05/15 . Refuses to sleep in bed because it is uncomfortable . On 04/14/15, a physician's orders [REDACTED]. (A Stryker matters is an electric air mattress with powered pressure redistribution). On 04/27/15 at 12:14 p.m., the director of nursing (DON) was asked if he could provide evidence the resident's concerns about the resident's mattress were addressed before 04/14/15. He was asked if staff looked at the mattress to determine if anything was wrong, was she offered another regular mattress, etc. The DON said the resident did not qualify for an air mattress. He explained the resident needed to have stage three (3) pressure ulcers or greater to qualify for a mattress. He stated he gave her the Stryker mattress when it became available; explaining another resident using the mattress left the facility. According to the DON, the facility owns the mattress. The DON was unable to provide evidence the facility investigated the resident's concerns about her mattress and attempted to accommodate the resident's when first reported in February 2015. The DON confirmed the resident was been sleeping in her bed since the new mattress was provided on 04/14/15. | 2018-04-01 |
| 6311 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 278 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the individual completing and certifying the accuracy of information for the sections he/she completed, failed to ensure two (2) minimum data sets (MDS) accurately reflected the status for one (1) of five (5) residents reviewed during a complaint survey. Resident #87's status regarding ambulation in and out of the room was not accurate. Resident identifier: #87. Facility census: 86. Findings include: a) Resident #87 Review of Resident #87's medical record, at 12:40 p.m. on 04/22/15, revealed the resident was readmitted to the facility on [DATE]. A five (5) day minimum data set (MDS), with an assessment reference date (ARD) of 03/09/15, was inaccurate related to ambulation in the room and corridor. Section G 0110, C and D of the MDS reflected Resident #87 walked in her room and in the corridor with supervision (oversight, encouragement or cueing). Further review of Resident #87's medical record revealed a 14-day MDS assessment, with an ARD of 03/14/15, also inaccurately reflected Resident #87 walked in her room and in the corridor with supervision (oversight, encouragement or cueing). in Section G0110, C and D. In an interview, at 10:15 a.m. on 04/24/15, the Clinical Reimbursement Coordinator (CRC)#113, was asked about Resident #87's ability to ambulate. She reviewed the MDSs with the ARDs of 03/09/15 and 03/14/15. The CRC confirmed they were inaccurate and did not reflect Resident #87's status in regards to ambulation. When asked what information she reviewed to determine if the resident had the ability to ambulate, she replied she used the Activities of Daily Living (ADL) sheets, which were completed by the nurse aides. Review of the ADL sheets revealed the area for walking in the hallway and in the resident's room was coded N/A (not applicable). The form also had several undocumented spaces in this area. The CRC also noted, on the MDS, the resident required supervision in this area. Medical record revealed the resident never walked alone, and only took a few steps with two (2) assistants. CRC #113 confirmed no observations and/or interviews were conducted regarding the resident's abilities prior to completing the MDS. | 2018-04-01 |
| 6312 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 323 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review, and policy review, the facility failed to provide an environment that was as free as possible from accident hazards over which the facility had control for one (1) of six (6) residents reviewed for accident hazards. The facility failed to evaluate and/or address injuries to Resident #72 when the resident alerted staff her injuries were caused by facility furnishings. Resident identifier #72. Facility census: 86. Findings include: a) Resident #72 On the morning of 04/23/15, at approximately 10:00 a.m., Resident #72 said she received an injury to the back of her legs from her toilet seat. She stated the toilet seat first pinched her left thigh and then she received another injury to her right thigh. She said the facility finally got her a new toilet seat but not until after she complained and complained. Review of the nursing notes found the following entries: -- 03/15/15 at 7:34 p.m., (name of resident) has a new onset/change in skin integrity as evidenced by abrasion. Location: Abrasion noted to back of left thigh, order noted for Exuderm, not demonstrating symptoms of pain . -- 03/29/15 at 8:46 p.m., The resident requested a padded toilet seat, . due to the toilet seat pinching the back of her legs while sitting on the seat . -- 03/30/15 at 8:26 p.m., (name of resident) has a new onset/change in skin integrity as evidenced by, Location: Orders noted to cleanse back of left and right upper thighs with WC (wound cleanser) apply calcium alginate and cover with border gauze change daily and prn (as needed) . Review of the treatment administration record (TAR) found an order written [REDACTED]. At 1:55 p.m. on 04/23/15, the wound care nurse, Registered Nurse (RN) #52 confirmed she treated abrasions to both the left and right upper thighs for Resident #72. When asked if she was aware the resident said the abrasions occurred as a result of her thighs being pinched by the toilet seat, RN #52 stated, I don't know if she actually pinched her leg or not, that is what she said. She verified an abrasion first occurred to the left thigh and then a few days later she had an abrasion to the right thigh. The RN said she did not investigate the allegations by the resident. She said she thought the areas occurred because she sat in her wheelchair all the time, refusing to bathe and refusing to sleep in her bed. At 5:30 p.m. on 04/23/15, the resident's injuries/abrasions were discussed with the director of nursing (DON). The DON was unable to provide evidence the facility investigated the resident's allegations that the toilet seat pinched her upper thighs causing abrasions. The DON stated, I would have expected an incident report, which we call a Risk Management Report. An incident report could not be located. According to the DON, the facility provided a new bariatric toilet seat because the resident wanted a new seat. When asked when the resident received the new seat, he stated he would get Central Supply Clerk (CSC)#111 and she would know. At 5:35 p.m. on 04/23/15, an interview was conducted with CSC #111 and the social worker (SW). The SSC stated she was not sure of the exact date, but she thought it was about two (2) weeks ago when she provided the new toilet seat to Resident #72. She said she was just told by a nurse to get the resident a toilet seat. The CSC said she was not provided information regarding injuries. The SW stated she believed the resident received the new toilet seat sometime during the Easter season, which was around the first week of April 2015. The SW confirmed she did not conduct an investigation into the resident's allegations related to the toilet seat causing injuries. At 5:45 p.m. on 04/23/15, the DON confirmed the facility had no evidence an investigation was conducted when the resident alleged she received an abrasion when the toilet seat pinched her left thigh on 03/15/15. Also, when the resident alleged a second injury, on 03/29/15, which she stated was due to the toilet seat, the facility did not investigate the injury. The DON was unable to provide evidence any staff member actually viewed and assessed whether or not the toilet seat caused the abrasions to the resident's left and right thighs. There was also no evidence the facility attempted to ascertain how the resident received abrasions to both the left and the right upper thighs. At 9:35 a.m. on 04/27/15, the DON provided a copy of the facility's policy entitled, Accident/Incidents. Review of the policy found the following information: (Name of company) staff will use the Risk Management System (RMS) to report, review, and investigate all accidents/incidents which occurred or allegedly occurred on Center property and involved, or allegedly involved, a patient who is receiving services . . An accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident/patient . . An incident can involve malfunctioning equipment or observation of a situation that poses a threat to safety or security . Purpose: . To provide standards for review and investigation of accidents/incidents. To define causative/contributing factors and institute preventive measures to avoid further occurrences . Assessment, Medical Assistance, Documentation: 2.1.1 The nurse will examine the patient . 2.1.6.1 Enter the accident/incident into RMS as a new event within 24 hours of the occurrence. 2.1.6.2 Document the accident/incident in the patient's chart; Documentation will include all pertinent information, date, time, place, notifications, and initial and ongoing assessments: Follow - up Investigation: The administrator, DON, or designee will review all accidents/incidents to determine if: Required documentation has been completed; and 4.1.2 Interventions to prevent further accidents/incidents have been identified and implemented . 4.4.1 Make every effort to ascertain the cause of the accident/incident; 4.42 Initiate actions to prevent further accidents/incidents; | 2018-04-01 |
| 6313 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 325 | E | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to recognize, evaluate, and/or address four (4) of ten (10) residents for potential need for nutritional interventions. Significant weight losses for these residents were documented shortly after their admissions to the facility. The facility did not implement their policy to confirm the weight losses and had not identified a need to assess each residents' nutritional status to determine if nutritional interventions were needed. Resident Identifiers: #17, #52, #64 and #72. Facility census: 86. Findings Include: a) Resident #17 Resident #17's medical record was reviewed at 1:00 p.m. on 04/27/15. The resident was admitted to the facility on [DATE]. This review revealed the following weights for Resident #17: 04/16/15 180 pounds (lbs.), 04/17/15 170 lbs., 04/28/15 168 lbs. Resident #17's weight was reviewed using the initial admission weight of 180 lbs., as documented on 04/16/15. On 04/17/15, the resident's weight was recorded as 170 lbs. This represented a weight loss of 10 lbs. (5.5%) in one (1) day. There was no evidence this weight loss was recognized or addressed. On 04/28/15 (12 days after admission), the resident's weight was recorded as 168 lbs. This represented a weight loss of 12 lbs. (6.67%) since admission. A weight loss of 5% in one (1) month is considered a significant weight loss. A weight loss of greater than 5% in one (1) month is considered a severe weight loss. There was no evidence this weight loss was recognized,assessed, or addressed or addressed. The medical record contained an initial nutrition assessment dated [DATE]. This assessment was completed by the Registered Dietitian (RD). It noted the resident's initial admission weight was 180 lbs. It also noted a 10 lb. weight discrepancy in 24 hours. The RD recommended weekly weights to establish baseline weights, and to liberalize the resident's diet to Regular (if approved by physician). Assistant Director of Nursing (ADN) #58 was interviewed at 2:30 p.m. on 04/27/15. She stated it appeared the resident's weight on the admission, which was done the day the resident was admitted to the facility, was 180 pounds. ADN #58 stated the facility re-weighed the resident on 04/17/15, and got the 170 lbs. weight. She said the admission weight of 180 lbs. obtained on 04/16/15 should have been struck out. Review of the facility's Weight Assessment and Intervention policy revealed a requirement to re-weigh any resident with a weight change of +/- (plus or minus) 5 pounds for confirmation. During an interview with the director of nursing (DON) at 3:30 p.m. on 04/27/15, he said, according to the facility's Weight Assessment and Intervention Policy, the facility should have re-weighed the resident when they obtained the weight of 170 which was a 10 pound variance from the initial admission weight of 180 pounds. The DON confirmed this policy stated, Any resident with a weight change of +/- 5 pounds will be re-weighed for confirmation. He stated the facility did not reweigh this resident for confirmation when there was a 10 pound weight variance on 04/17/15. The DON stated the resident's weight was not confirmed as required by their policy. The DON stated he could not say for sure why staff re-weighed the resident on 04/17/15. He also stated he could not say for sure if that weight was accurate because a re-weigh was not obtained, nor was the original admission weight struck-out as an error. Resident #7's assessment by the RD was based upon a weight which the facility now asserts was inaccurate; however, interventions were not implemented at the time the weight records showed weight losses. In addition, this resulted in the facility's inability to accurately assess the resident's nutritional needs to ensure she maintained appropriate parameters of nutritional status. b) Resident #52 At 3:00 p.m. on 04/27/15, the resident's weights were reviewed with the director of nursing (DON). On 04/14/15, the date of the resident's admission, the facility recorded the resident's weight as 189 pounds. On 04/17/15 the resident's weight was recorded as 169 pounds. On 04/22/15, the dietitian completed a nutritional assessment. The assessment noted the resident's 20 lbs. weight loss which occurred within seventy-two (72) hours of admission to the facility. The original weight of 189 lbs. was struck out on 04/27/15 at 11:16 a.m., by ADON). This was ten (10) days after the 20 lb. weight loss was noted on 04/17/15. There was no evidence a re-weigh was obtained when the weight loss was originally noted on 04/17/15. Further review of the medical record, on 04/27/15, found a progress note completed by the ADON at 3:53 p.m. on 04/27/15. This progress note read . Residents admission weight was 189 lbs. Resident was re-weighed 3 days later at 169 lbs. First weight was incorrect, last weight obtained was 159, which is a 10 lb. weight loss. Resident upon admission had a large amount of [MEDICAL CONDITION] noted to right leg related/to recent [MEDICAL CONDITION]. [MEDICAL CONDITION] at this time has now decreased and could be the cause of the weight loss. Will continue to monitor resident through next review. An interview with the DON was conducted at 3:30 p.m. on 04/27/15. He said, according to the facility's Weight Assessment and Intervention Policy, the facility should have re-weighed the resident when they obtained the weight of 169 which was a 20 pound variance from the initial admission weight of 189 pounds. The DON stated the resident's weight was not confirmed as required by their policy. The DON stated he could not say for sure why staff re-weighed the resident on 04/17/15. He also stated he could not say for sure if that weight was accurate because a re-weigh was not obtained. The original admission weight was struck-out as an error on 04/27/15. At the time of the interview, there was no related progress note. Resident #52's assessment by the RD were based upon a weight which the facility now asserts was inaccurate; however, interventions were not implemented at the time the weight records showed weight losses. In addition, this resulted in the facility's inability to accurately assess the resident's nutritional needs to ensure she maintained appropriate parameters of nutritional status c) Resident #64 At 3:05 p.m. on 04/27/15, the resident's weights were reviewed with the DON. On 04/03/15, the date of the resident's admission, the facility recorded the resident's weight as 185.6 pounds at 6:55 p.m. On 04/10/15 at 10:15 a.m. the resident's weight was recorded as 183 pounds. On 04/17/15 at 11:23 a.m. the resident's weight was recorded as 173 pounds. At 3:30 p.m. on 04/27/15, the DON said, according to the facility's Weight Assessment and Intervention Policy, the facility should have re-weighed the resident when they obtained the weight of 173 which was a 10 pound (5.4%) variance from the previous weight of 183 pounds. The DON confirmed the re-weigh policy was not implemented as required when the resident had a weight change of +/- 5 pounds. He stated the facility did not re-weigh this resident for confirmation when there was a 12.6 pound weight variance on 04/17/15. d) Resident #72 At 5:05 p.m. on 04/27/15, the resident's weights were reviewed with the DON. On 02/12/15, the date of the resident's admission, the facility recorded the resident's weight as 322 pounds at 8:20 p.m. On 02/13/15 at 2:32 p.m. the resident's weight was recorded as 302 pounds. The DON said the discrepancy could have occurred because the resident was weighed on the lift on 02/12/15, and on 02/13/15, she was weighed in the chair. When asked if the facility had any evidence the twenty (20) pound weight difference was investigated, the DON replied, No. When asked if being weighed on different scales would account for a twenty (20) pound weight loss, the DON said, They might be off a few pounds. The DON confirmed the facility should have noticed the difference in the weights and re-weighted the resident. On 02/18/15, the dietitian completed a nutritional assessment. The assessment did not address the resident's 20 pound weight loss which occurred within twenty-four (24) hours of admission to the facility. | 2018-04-01 |
| 6314 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 329 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed was free from unnecessary medication. Resident #7 received excessive doses of [MEDICATION NAME] (Miritazapine), an antidepressant. Resident identifier: #7. Facility census: 86. Findings include: a) Resident #7 A review of Resident #7's medical record, at 10:15 a.m. on 04/27/15, found a 01/22/15 physician's orders [REDACTED]. Prior to this order, Resident #7 was receiving 7.5 mg of [MEDICATION NAME] every night. The Medication Administration Record [REDACTED]. The previous ordered dose of [MEDICATION NAME] 7.5 mg was also initialed as given on 01/23/15, 01/24/15. 01/25/15 and 01/26/15. This resulted in Resident #7 receiving 22.5 mg of [MEDICATION NAME] on 01/23/15, 01/24/15, 01/25/15, and 01/26/15, when she was ordered and should have only received 15 mg of [MEDICATION NAME] on each of these days. An interview with the Director of Nursing (DON), at 11:00 on 04/27/15, confirmed Resident #7's January 2015 MAR indicated [REDACTED]. | 2018-04-01 |
| 6315 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 356 | C | 1 | 0 | J5M711 | Based on observation of the staff posting and staff interview, the facility failed to post staffing information that accurately reflected the current date, the total number and actual hours worked by registered nurses, licensed nurses, certified nurse aides per shift, and the current resident census. This had the potential to affect all residents and/or visitors residing or visiting the facility. Facility census: 86. Findings include: a) Observation of the staff posting, during the initial tour of the facility, at 11:25 a.m. on 04/22/15, found the facility staff posting was dated 04/21/15. An interview with the director of nursing, at 11:30 a.m. on 04/22/15, confirmed the facility had not displayed the staff posting information for 04/22/15. | 2018-04-01 |
| 6316 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 514 | D | 1 | 0 | J5M711 | **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 ten (10) residents whose medical records were reviewed. Resident #7's Medication Administration Record [REDACTED]. In addition, nurses documented the resident was administered medication which was not available in the facility for administration. Resident identifier: #7. Facility census: 86. Findings include: a) Resident #7 Review of Resident #7's medical record, on 04/27/15 at 10:15 a.m., revealed a new order on 01/22/15 to increase [MEDICATION NAME] ([MEDICATION NAME]) to 15 milligrams (mg) by mouth (po) at night for weight loss. The Medication Administration Record [REDACTED]. In addition, further review of the medical record found the documentation on the MAR for 03/01/15 through 03/17/15 and the MAR for 04/01/15 though 04/02/15, indicated the resident received both the [MEDICATION NAME] 7.5 mg and the [MEDICATION NAME] 15 mg po at bedtime on these dates. During an interview with the Director of Nursing (DON), on 04/27/15 at 11:00 a.m., he acknowledged the MARs for both [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg and 15 mg. were initialed as given 03/01/15 through 03/17/15 and 04/01/15 though 04/02/15. The DON said it was a paper error, as the pharmacy had only supplied the nurses with [MEDICATION NAME] 15 mg since 01/23/15. The DON said the facility did not received [MEDICATION NAME] 7.5 mg after 01/23/15; therefore, the nurses could not have administered the 7.5 doses, even though they documented it was administered. | 2018-04-01 |
| 6317 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 241 | D | 0 | 1 | 6PKC11 | Based on observations and staff interview the facility failed to promote the dignity for two (2) residents dining in the 100 hall dining room. The two (2) residents were not provided their meals at the same time as their tablemates. Resident identifiers: #107 and #68. Findings include: Observations on 4/14/2014 at 12:02 PM revealed four residents were seated at one table in the 100 hall dining room. Two of the four residents, #107 and #68, were observed to be eating their meals and the other two residents had not yet received their meals. The two residents who had not received their meals were observed to watch as the other two residents were fed their lunch by one staff member. The two residents being fed by staff had consumed their entire meal before the other two residents were served their meal tray. Interview with Staff #17 - Stated the two residents would have to wait to be assisted with their meals until a staff member was available to assist them as they both required the assistance of a staff member to eat. She stated a lot of residents in 100 Hall dining room require assistance to be fed so the staff feed residents as they can. Interview with Staff #77 during lunch service revealed the lunch trays come to the dining room for all residents at the same time and they just take the trays and feed the residents as they can. She stated they have a lot of residents on this unit who need assistance to be fed and there are only so many staff available to feed at one time. Interview with the dietary manager on 4/16/2014 at 1:30 PM revealed they had identified a concern with residents on 100 Hall having to wait for assistance to be fed. She stated they had made a change to how breakfast was served so residents would receive assistance with their meals more timely, but they had not made any changes to the the lunch or supper meal services. She verified all the meal trays for all the residents were brought to the 100 Hall dining room for lunch at the same time. She verified they needed to adjust the delivery of the meal trays to ensure all residents at one table receive their meal and assistance at the same time. | 2018-04-01 |
| 6318 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 242 | D | 0 | 1 | 6PKC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews and staff interview, the facility failed to honor resident choices regarding how often they would like to receive a shower or bath. This affected 3 of 12 residents interviewed in Stage 1. Resident identifiers #7, #91, and #22. Findings include: 1. Review of Resident #7's clinical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The Admission History and Physical dated 12/31/2013 documented the resident was alert and oriented. Review of the Admission Minimum Data Set assessment dated [DATE] revealed the resident scored a 14 on the Brief Interview for Mental Status, indicating intact cognition. The resident was further assessed to require extensive assistance of two staff members with bathing and that is was very important for him/her to choose mode of bath. The clinical record was silent for assessment of bathing frequency preferences. Review of the current care plan dated 04/02/2014 revealed the following care plan problem: ADL FUNCTIONAL AND PREFERENCES ADL Customary Routine Preferences, expressing interest in specific activities. The care plan goal included preferences in routine will be respected where/whenever possible. The care plan interventions were silent for bathing frequency preferences. During interview on 4/15/2014 1:12 PM, Resident #7 stated I take a tub bath on Sunday and Wednesday night as scheduled by the facility and stated I was never asked how often I would like to bathe. During interview on 4/15/2014 at 3:50 PM, staff member #24 verified they did not assess bathing preferences on admission or at any other times. Staff stated they assess bath mode and will assign the resident a schedule for bathing usually twice weekly. During interview on 4/16/2014 at 7:30 AM, Resident #7 stated he/she would prefer to bathe at least three times per week. 2. Review of Resident #91's clinical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] assessed the resident's ability to choose mode of bath as very important. The resident was assessed as a two person extensive assist with bathing. The resident scored an 11 on Brief Interview for Mental Status indicating moderately impaired cognition. Further review of the clinical record was silent for an assessment of bathing frequency. Review of the current care plan dated 1/28/2014 revealed the following care plan problem: ADL FUNCTIONAL AND PREFERENCES ADL Functional Deficit, compromised balance, depression, cognitive impairment, [MEDICAL CONDITION], anxiety and backache. The care planning interventions were silent for bathing preferences. During interview on 4/15/2014 at 2:22 PM, Resident #91 stated I was not asked how often I would like to take a bath, it was just scheduled twice per week. During interview on 4/15/2014 at 3:50 PM, staff member #24 verified they did not assess bathing preferences on admission or at any other times. Stated they assess bath mode and will assign the resident a schedule for bathing usually twice weekly. 3. Resident #122 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of resident's clinical record revealed the Admission Minimum Data Set assessment documented Resident #122 scored a 15 on the Brief Interview for Mental Status indicating intact cognition. This MDS also documented the resident required the assistance of one staff for bathing. During an interview with Resident #122 on 04/14/2014 10:55 AM, resident stated he/she was not able to participate in choosing how many times a week a bath or shower was provided. Resident stated staff set the schedule for when showers are received. Resident stated shower schedule is set for Saturday and Wednesday, but resident would really like to have a shower at least three times a week. Further interview with Resident #122 on 4/15/2014 at 2:20 PM revealed resident is only here for a short time and is going to be discharged to a private apartment, but while here, would like to have a shower at least three times a week. Resident stated he/she was not asked during initial admission how often he/she would like to have a shower. Interviewed Staff #24 on 4/15/2014 at 3:50 PM and staff verified they did not assess bathing preference schedules on admission or at any other time. Stated they assess bath mode and will assign the resident a schedule for bathing usually twice weekly. | 2018-04-01 |
| 6319 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 253 | E | 0 | 1 | 6PKC11 | Based on observations and staff interview, the facility failed to maintain interior walls, woodwork, and wood doors in resident's rooms. This affected 20 of 58 rooms where residents resided in the facility. Findings include: An environmental tour was done on 4/16/14 at 12:15 P.M. with the Maintenance Director #9. The following residents' rooms and bathrooms with observed on the tour: 109, 111, 205, 206, 207, 208, 209, 211, 213, 302, 303, 304, 305, 306, 307, 309, 406, 408, 411 and 414. They were observed with marred walls, chipped drywall, chipped wood trim and chipped wood on bathroom doors. The following rooms were identified with environmental concerns. Room 109,111, 205, 206 and room 207 were observed with marred woodwork around the closet doors. Room 208 was observed with chipped wood around the closet door and bathroom door. Room 209 was observed with chipped wood around the closet door and the wall was chipped by the the closet. The bathroom door and the bathroom trim had chipped wood. There were black marks on the bathroom walls. Room 211 was observed with chipped wood trim around the closet doors, chipped wood on the bathroom door, chipped drywall behind the trash can in the bathroom and chipped drywall beside the closet doors. Room 213 was observed with chipped wood trim around the closet doors and chipped wood on the bathroom door. The drywall was chipped behind the trash can in the bathroom. Room 302 was observed with holes in the drywall in the bathroom and black marks on the wall. Room 303 was observed with chipped drywall in the bathroom and chipped wood on the bathroom door. Room 304 was observed with chipped paint on the bathroom door frame, chipped drywall by the bathroom door and chipped drywall in the bathroom. Room 305B was observed with chipped wood on the room door and chipped drywall in the bathroom and the head of the resident's bed. Room 306 was observed with chipped paint on bathroom door frame, chipped drywall on bathroom walls and chipped wood on the bathroom door. Room 307 was observed with chipped wood on bathroom door. Room 309 was observed with chipped drywall and paint on the bathroom walls. Room 406B was observed with marred walls behind the bed, marred walls in the bathroom and scraped wood on the bathroom door. Room 408 was observed with rough edges and a hole in the wood bathroom door. Room 411B was observed with exposed metal on the corner of the wall by the end of the bed and chipped wood on the bathroom door. Room 414A was observed with marred walls near the bed and in the bathroom. Maintenance director #9 verified the above mentioned rooms were in need of repair related to the marred walls, chipped wood trim, paint, drywall and chipped bathroom doors. | 2018-04-01 |
| 6320 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 282 | D | 0 | 1 | 6PKC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to implement the plan of care for one (1) resident of 16 residents whose care plans were reviewed in Stage 2. Resident identifier: #107. Findings include: Resident #107 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the the most recent Minimum (MDS) data set [DATE] found the resident was severely cognitively impaired, had long and short term memory loss and required the assistance of one staff for eating. The current care plan, dated 4/3/2014, documented Resident #107 was nutritionally compromised with a potential for further decline due to weight loss and low body mass index (BMI). One of the nutrition care plan goals was to provide a dietary supplement of Ensure 8 oz three times a day between meals and at bed time. Interventions were added to the nutrition care plan on 12/27/13 to add double portions at breakfast and increase his/her nutritional supplement (ensure) to 120 ml three times a day. On 2/17/14 a new intervention was added to increase his/her Ensure to 6 oz 3 x a day and on 3/14/14 the Ensure was increased to 6 oz to 8 oz three times a day. Review of the intake logs for 2014, where the staff were required to document the consumption of Resident 107's nutritional supplement, revealed many days with documentation missing. Interview with Staff #77 on 4/16/2014 in 100 hall dining room at 1:33 PM revealed staff that dispense residents' supplements would be required to document how much the resident consumed. She stated they are required to document this in the nurse aide computer. Review of this documentation was located on a report called the Meal Intake Detail Report. Review of this report for Resident #107 for January 2014 revealed staff failed to document consumption of dietary supplement for the morning snack for 19 of 31 days. They failed to document consumption of the afternoon snack in January 2014 for 16 of 31 days and for 5 days of 31 for the evening snack. In February 2014, staff failed to document consumption of dietary supplement for the morning snack for 14 of 28 days, afternoon snack in February 2014 for 12 of 28 days, and for 3 of 28 days for evening snack. In March 2014, the facility failed to document Resident #107's morning dietary supplement for 10 of 31 days, afternoon dietary supplement consumption for 19 of 31 days and evening supplement consumption for 4 of 31 days. In April 2014, staff failed to document morning supplement for 9 of 15 days, afternoon supplement for 6 of 15 days and evening supplement for 6 of 15 days. Interview was conducted with Staff #23, dietary manager, and Director of Nursing on 4/16/2014 at 1:50 PM regarding the lack of documentation of the residents' dietary supplements. Staff #23 and DON stated they had identified a concern in March 2014 with staff failing to consistently document consumption of residents' dietary supplements, but no monitoring or audits of this concern were provided. The care plan intervention for the nutritional supplement being given 3 times a day was not consistently implemented for Resident 107. . | 2018-04-01 |
| 6321 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 325 | D | 0 | 1 | 6PKC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure one of four residents identified as underweight in a sample of 40 residents from Stage 1 was provided nutritional care and services to maintain acceptable parameters of nutritional status. Resident #107, who was documented with low body weight, was ordered a dietary supplement to promote weight gain. There was a lack of evidence the dietary supplement was consistently provided and/or consumed. Findings include: a) Resident #107 The resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the the most recent Minimum Data Set data 01/07/14 revealed documentation the resident was severely cognitively impaired, had long and short term memory loss, and required the assistance of one staff for eating. The current nutrition care plan dated 4/3/14 documented Resident #107 was nutritionally compromised with a potential for further decline due to weight loss and low body mass index (BMI). The nutrition care plan goal was to attempt to maintain weight at 103-110 pounds. Interventions included provide assistance with meals and record meal intake. Interventions also included were to provide a regular diet as ordered with double portions at breakfast and oral supplement Ensure 8 oz three times a day between meals and at bed time. The nutrition care plan and dietary notes revealed documentation on 12/27/13 of an intervention to increase the dietary supplement of Ensure to 120 ml 3 times a day. On 2/17/14, Ensure was increased to 6 oz 3 x a day and on 3/14/14, increased to 8 oz 3 times a day due to weight loss. Review of the weight record revealed Resident #107's weights were as follows: 09/22/13 .123 10/20/13 .119 11/18/13 .117 12/15/13 .111 01/12/14 .112 02/09/14 .108 03/09/14 .103 040/8/14 .107 Review of the Meal Intake Detail report for Resident #107 revealed no evidence the resident received or consumed snacks in January 2014 as follows: -- morning snack for 19 of 31 days -- afternoon snack for 16 of 31 days -- evening snack for 5 of 31 for In February 2014, there was no evidence the resident received or consumed dietary supplements or snacks as follows: -- dietary supplement for the morning snack for 14 of 28 days -- afternoon snack for 12 of 28 days -- evening snack for 3 of 28 days In March 2014, there was no evidence the resident received or consumed dietary supplements as follows: -- morning dietary supplement for 10 of 31 days -- afternoon dietary supplement for 19 of 31 days -- evening supplement for 4 of 31 days. In April 2014, there was no evidence the resident received or consumed supplements or snacks as follows: -- morning supplement for 9 of 15 days -- afternoon supplement for 6 of 15 days -- evening supplement for 6 of 15 days Interview with Staff #77 on 4/16/2014 in the 100 hall dining room at 1:33 PM revealed the staff that gives the residents their supplements was required to document how much the resident took in the nurse aide computer. An interview was conducted with Staff #23, the dietary manager, and the Director of Nursing on 4/16/2014 at 1:50 PM regarding the lack of evidence of the resident's receipt and consumption of dietary supplements. Staff #23 stated they had identified a concern with the staff failing to consistently document the consumption of resident's dietary supplements in March 2014. No monitoring audits regarding this were supplied by Staff #23. The dietary supplement was ordered 3 times a day to prevent further weight loss and promote weight gain for Resident #107. The facility failed to have evidence Resident #107 consistently received or consumed this dietary supplement to promote weight gain. This information was necessary to determine whether the plan for nutritional care was working and/or if it required modification. | 2018-04-01 |
| 6322 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 252 | E | 0 | 1 | 5EN111 | Based on observation and staff interview, the facility failed to ensure the environment where residents live was comfortable and homelike. The area designated as a resident sitting area was in the corner area of the dining room. It contained rocking chairs, a sofa, and a television. Empty wheelchairs and geri-chairs were observed stored in front of the furniture preventing access to residents or visitors who desired to sit in these chairs. The residents who were seated in their wheelchairs were sitting in an area where the empty wheelchairs were stored. This did not create a pleasant homelike sitting area. This practice had the potential to affect more than an isolated number of residents. Facility Census: 55. Findings include: a) During an observation on 07/15/14 at 8:00 a.m., the area in the corner of the dining room was observed. This area had carpet, a television, a couch, and several rocking chairs. It was designated as a sitting area where residents could sit and/or watch television. Eight (8) empty wheelchairs were observed stored in the area, blocking access to the rocking chairs and the sofa. On 07/16/14 at 4:00 p.m., nine (9) empty wheelchairs and four (4) empty geri-chairs were observed stored in the dining room. Six (6) of the empty chairs were in the television area in front of the rocking chairs. This prevented access to the area by any resident who desired to sit in the rocking chairs or on the couch. During a confidential employee interview, a nursing assistant was questioned about the chairs being stored in the resident sitting area in the corner of the dining room. The nursing assistant replied, That is where they told us we have to put them. The dining area was observed on various days and times during the survey from 07/15/14 to 07/23/14. There were always several wheelchairs and geri-chairs stored in the resident sitting area. A tour was conducted with the Environmental Service Supervisor (Employee #23) and the facility administrator (Employee #78) on 07/23/14 at 12:00 p.m. They were made aware of the observations, throughout the survey, of the chairs stored daily in the residents' sitting area. They agreed this was not a homelike environment. | 2018-04-01 |
| 6323 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 253 | D | 0 | 1 | 5EN111 | Based on observation and staff interview, the facility failed to ensure effective housekeeping and maintenance services. Four (4) rocking chairs and a geri-chair in the common area designated as a sitting area for residents, were observed with tears, rips, and/or with stuffing of the upholstery exposed. The condition of these items rendered them unable to be effectively sanitized. This practice had the potential to affect more than an isolated number of residents. Facility Census: 55 Findings include: a) On 07/15/14 at 8:00 a.m., four (4) rocking chairs and a geri-chair were observed with tears and rips in the upholstery, and the stuffing was exposed around the bottom parts of the chairs. A tour was conducted with the Environmental Service Supervisor (Employee #23) and the facility Administrator (Employee #78), on 07/23/14 at 12:00 p.m. Observations were made of the four (4) rocking chairs and the geri-chair. They agreed the condition of the rocking chairs and the geri-chair upholstery could result in improper sanitization of the chairs. | 2018-04-01 |
| 6324 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 272 | D | 0 | 1 | 5EN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of three (3) residents reviewed in Stage 2 for dental services. The minimum data set (MDS) assessment did not indicate the resident had [MEDICAL CONDITION] on his lower lip. Resident identifier: #14. Facility census: 55 Findings include: a) Resident #14 Resident #14 was admitted to the facility on [DATE]. During an interview with the resident, on 07/15/14 at 9:30 a.m., four (4) black round [MEDICAL CONDITION] were observed on the resident's lower lip. The resident said he believed the spots were from smoking. Review of the resident's admission MDS, with an assessment reference date of 05/21/14, found Section L, related to dental status, did not indicate the resident had [MEDICAL CONDITION] on his lower lip. The failure to indicate the [MEDICAL CONDITION] on the MDS was brought to the attention of the director of nursing (DON). At 1:07 p.m. on 07/23/14, the DON confirmed the [MEDICAL CONDITION] were not identified on the resident's MDS. | 2018-04-01 |
| 6325 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 332 | D | 0 | 1 | 5EN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, the facility failed to ensure a medication error rate of less than five (5) percent. Resident #33's eye drops were not instilled to make contact with the conjunctival sac, and was not washed over the eye for optimal absorption. Also, Resident #13 did not receive the specific Calcium preparation as ordered by the physician. Two (2) errors, of the thirty-one (31) opportunities observed, resulted in a medication error rate of 6.45%. This practice affected two (2) of five (5) residents observed during medication administration observations. Resident identifiers: #13 and #33. Facility Census: 55. Findings include: a) Resident #13 During medication administration observation, on 07/17/14 at 8:30 a.m., Employee # 24 administered one (1) Calcium 600 mg (milligram) + D tablet by mouth to Resident #13. Review of the physician's orders [REDACTED]. The medication observed administered by the nurse was not the same as that ordered by the physician. b) Resident #33 During medication administration observation, on 07/17/14 at 9:20 a.m., Employee #24 was observed administering an eye drop medication, [MEDICATION NAME] ([MEDICATION NAME]) one (1) drop to each eye. The nurse (Employee #24) pulled the resident's upper eyes open from the eye brows and instilled the drop in each eye from the top. Observation revealed the drops did not make full contact with the eye. The facility policy titled Instillation of Eye Drops was reviewed on 7/18/14. The section stated Steps in the Procedure stated: Step 7- Gently pull the lower eyelid down. Instruct the resident to look up. Step 8- Drop the medication into the mid lower eyelid (fornix). Step 9- Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops. These steps were not performed when Employee #24 administered the eye drops. On 7/23/14 at 11:00 a.m., the Director of Nursing was made aware of the technique observed for administration of the eye drops. She stated this was not the proper way to administer eye drops. She also stated in-service training for Employee #24, on the procedure for properly administering eye drops, had already been completed. | 2018-04-01 |
| 6326 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 356 | B | 0 | 1 | 5EN111 | Based on Review of the POS [REDACTED]. This practice had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) Review of the facility's posted nursing staffing information, on 07/11/14 , indicated three (3) registered nurses were working the day shift. Review of the staff schedule indicated only one (1) registered nurse was scheduled for direct care on 07/11/14. This information was reviewed with Employee # 76, the director of nursing (DON), on 07/23/14 at 11:00 a.m. She stated, The nurse who filled this out must have counted me and the other nurse. The other nurse was identified as the minimum data set assessment nurse. The DON confirmed she and the MDS nurse were not performing direct care that day, and should not have been counted on the posting. | 2018-04-01 |