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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1591 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 550 | D | 0 | 1 | 5JPY11 | Based on observation, policy and procedure review and staff interviews, the facility failed to ensure residents were treated with dignity and respect. Resident #47 did not receive her meal at the same time as her tablemate. Resident #108 lower body was exposed during personal care. These observations were random opportunities for discovery. Resident identifiers: #47 and #108. Facility census: 61. Findings included: a) Resident #47 Observation of the noon meal at 12:27 AM on 07/09/18, found Residents #47 and #46 seated at a table together. Resident #46 received her tray. Staff then served Residents #158, #11, #49, and #43, who were seated together at another table. Resident #6, who sat alone at a table in the back of the dining room, received a tray. Staff served residents seated at two (2) separate tables before returning to serve Resident #47. At 12:32 PM on 07/09/18, the activities director, Employee #15 said Resident #47's tray came out on the cart going to the hallways because, You never know where she is going to be. At 9:43 AM on 07/12/18, the Director of Nursing was advised of the above dining room observation. The DoN said she was aware of the issue. b) Resident #108 A random observation of Hall 100 on 07/11/18 at 7:50 AM, found Nurse Aide (NA) #45 and NA #46 repositioning Resident #108. The door to the resident's room was open and Resident #108 was uncovered and exposed from the waist down to anyone passing by in the hallway. During an interview on 07/11/18 at 7:55 AM, NA#45 and NA#46 said the door should have been closed. NA #46 further stated he/she, Usually shuts the door, but didn't think of it. A review of the facility's policy and procedure OPS213, Treatment: Considerate and Respectful, Section 1.8, Privacy found it instructed, Maintain patient privacy of body including Patient sufficiently covered. An interview with the Administrator on 07/11/18 at 8:35 AM, confirmed facility staff should adhere to the policy to avoid exposing a resident during care. | 2020-09-01 |
| 1592 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 584 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, and staff interview, the facility failed to provide a safe, clean, comfortable and homelike environment. Residents room with strong foul odor of urine reaching the hallway and heavy brown stains of urine on floor and an electrical outlet box lying on the floor in urine. This was a random opportunity for discovery. Identified Resident #37. Facility census 61. Findings included: a) Upon entry to the facility on [DATE] at 11:08 AM, a strong foul odor of urine was noticed before reaching the doorway of the room that was the source. The room, belonging to Resident #37, had a brown stain on the floor between the bed and window and under the air conditioner. The air conditioner, that was not on, was plugged into a metal electrical box that was on the floor in what appeared to be urine. During an interview on 07/09/17 at 3:58 PM, the residents brother said his brother received good care at the facility, but the only problem he had was the room smelled so bad. He stated he had spoken to the administrator countless times in the past about the room being dirty and smelling. He also was concerned about the facility turning off his brother's air conditioner so that he could not control the temperature of his own room. He said he was told that because his brother urinated in the air conditioner unit, they turned it off. He stated that did not address the problem with the odor along with the stains on the floor. He said his brother now has a fungal infection on his body folds from not having air conditioning on the very hot days. During an interview on 07/10/18 at 9:59 AM, Housekeeping Supervisor (HS) #4 said she and her boss decided to strip and wax the floor. She also said that her boss said it would not last, because of him urinating on the floor. She was asked how long does urine have to be on the floor before it causes those heavy large brown stains and the strong odor? Her response was, Housekeeping is only here 8 hours a day and I get many complaints about the one hundred hall (this is the hall this resident's room is on) stinking but it's because of this room. She agreed that the urine would have to be on the floor for a while to cause that much staining. She also said, Housekeeping is not supposed to clean up urine that is a nursing job. We/housekeeping stays busy if doing his laundry. During an interview on 07/10/18 at 10:08 AM, DON said that the Nursing Aides (NA) do clean up the urine at times because she has heard them talking about. During an interview on 07/10/18 at 8:36 AM, NA #82 said the air conditioner/heater unit was working. She then attempted to demonstrate that it was in working order, but it would not come on. The air conditioner remained plugged into the electrical box on the floor lying on the brown stains. During an interview on 07/10/18 at 8:37 AM, the Administrator said she was unaware of the floor being stained because they were supposed to be mopping his room daily. She was also unaware that his air conditioner was not working. She was informed of the pungent smell of urine in his room on 07/09/18. On 07/10/18, his room odor was less and smelled like air freshener and urine. The Administrator nodded her head in agreement. During an interview on 07/10/18 at 8:53 AM, Maintenance Supervisor (MS) #18 said he was aware that this resident's air conditioner unit was not working and had been off for one month or more. He stated he was afraid the resident would get electrocuted, so he turned the breaker off. He stated that the resident had a fan in his room and as far as he knew, the resident had not complained; however, he agreed the resident did not have the capacity to know to complain. At that time the resident is being treated for [REDACTED]. This most likely is associated with warm moist areas. During an interview on 07/10/18 at 2:04 PM, HS #4 was deep cleaning Resident # 37's room. MS #18 related a shield was placed on the air conditioner unit to prevent urine from going into the unit and power had been restored Resident #37's room. The metal electrical box was still lying on the floor which was pointed out again to MS#18. MS #18 said that he was unaware of that and would fix it when housekeeping is done. Review of Resident Council meeting minutes dated 03/30/18 and 06/27/18 revealed there were complaints of foul odors and both times housekeeping had determined the odors were from the room belonging to Resident #37. Documents from HS #4 revealed housekeeping had power scrubbed this resident's bathroom in (MONTH) and (MONTH) and his room and bathroom on 06/15/18. Upon entering the facility on 07/11/18 at 7:30 AM, the smell of urine back lingered in the resident's room and into the hallway. The odor was noticed by two other surveyors. During an observation on 07/11/18 at 9:25 AM, the resident's bed was stripped and air drying. The offensive odor had lessened. During an observation on 07/12/18 at 7:28 AM, Resident #37's room continued to have a mild odor of urine. | 2020-09-01 |
| 1593 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 585 | E | 0 | 1 | 5JPY11 | Based on Resident Council interviews, observation, and staff interview, the facility failed to ensure residents had access to information on how to file a grievance or complaint. This had the potential to affect more than an isolated number of residents. Facility Census: 61. Findings included: a) On 07/10/18 at 1:57 PM, prior to beginning an interview with ten (10) residents that attended the Council Meeting, Resident #24, the wife of the Resident Council President, stated, Before we get started we would like to have the Activities Director (AD) and Administrator (NHA) in our meeting. When the Administrator and Activities Director came in the room, Resident #24 said, See I told you that I would get you in this meeting like you wanted. After a lengthy discussion on how they (all the residents at the meeting) loved everything and loved all the staff, it was learned that none of the residents knew where the grievance or complaint information was or how to file one. The activities director and administrator stated the forms were not placed out for the residents to use as they wished at that time but would find a place to have them readily available. They both agreed that it was the right of the residents to have these forms and information available. | 2020-09-01 |
| 1594 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 607 | L | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review, staff interview, and review of the facility's policy for screening of employees, the facility failed to verify two (2) of four (4) direct care staff hired by a staffing agency and used by the facility were thoroughly screened for a history of abuse, neglect, exploitation, and/or any applicable criminal activity that would identify the individual as unfit to work in a long-term care facility. The facility failed to ensure two (2) of three (3) individuals were screened through the West Virginia Clearance for Access and Employment Screening (WV CARES) system, a program initiated by the Centers for Medicare and Medicaid Services (CMS) National Background Check Initiative. Employee identifiers: #64 and #7. After consultation with the State Agency, a determination of immediate jeopardy was made based on the facility's failure to thoroughly screen the backgrounds of two (2) of three (3) Licensed Practical Nurses (LPNs). In addition, two (2) of three (3) LPNs did not have proof of West Virginia Licensure and were currently working at the facility. This practice had the potential to affect all residents residing in the facility. Notice of the immediate jeopardy (IJ) was given to the Administrator on [DATE] at 6:19 PM. An acceptable plan of correction (P[NAME]) was received from the Administrator on [DATE] at 6:35 PM. After verification of the implementation of the plan of correction (P[NAME]), the immediate jeopardy (IJ) was abated on [DATE] at 6:35 PM. After removal of the immediate jeopardy, a deficient practice remained at a scope and severity of [NAME] for this requirement for failure to ensure Nurse Aide #83 maintained a current registration. Facility census: 61 The findings included: a) LPN #64 A review of personnel files, on [DATE] at 3:00 PM, revealed the facility had employed agency staff, LPN #64 on [DATE]. When the employee files were brought to the surveyor for review, the file for Employee LPN #64 was not included. When this omission was brought to the Administrator's attention on [DATE] at 3:06 PM, the Administrator stated, The employee's file is here in the facility and I was trying to find it. On [DATE] at 4:01 PM, Corporate RN #87 stated there was no employee file for LPN #64 at the facility. It was verified at that time that LPN #64 was currently on the schedule to work and had been working in the facility since [DATE]. A review of the time record for LPN #64 on [DATE] at 4:02 PM, revealed the employee worked at the facility on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] ,[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. LPN #64 was scheduled to also work [DATE] from 6:45 PM-07:15 AM. b) LPN #7 A review of personnel files on [DATE] at 03:00 PM, revealed the facility employed agency staff, LPN #7 on [DATE]. The file did not contain documentation that LPN #7 had been screened by WV CARES system for background information. Additionally, LPN #7's LPN license was for a distant state, and there was no evidence of current West Virginia licensure. An interview with the facility administrator on [DATE], at 3:06 PM, verified LPN #7 did not have a background check completed through WV CARES and had only the license from another state on file. Further interview on [DATE], at 4:01 PM with Corporate RN#87, revealed there was no background check completed on LPN #7 through WV CARES and they only had proof of a LPN license from another state. Employee LPN#7 was hired to work at the facility 0n [DATE]. A review of the time records for dates worked were as follows: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and was working on the unit providing direct care when the deficient practice was discovered on [DATE]. c) A review of the facility's policy, OPS300 Abuse Prohibition included, The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. (Refer to Human Resources Policies and Procedures, Background Investigations policy.) 2.1 The Center will not employ or otherwise engage individuals who 2.1.1 Have been found guilty by a court of law of abuse, neglect, exploitation, misappropriation of property, or mistreatment; or 2.1.2 Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. 2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service will be reported to the state nurse aide registry or licensing authority; 2.1.3 Have had a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [REDACTED].>or misappropriation of resident property. The facility's failure to follow its policy, failure to verify whether employees had current licenses to practice in the State of West Virginia, and to obtain or verify background checks were completed through the WV CARES system to determine whether these employees were eligible to work with the nursing home residents, placed all resident of the facility at risk for serious harm. These findings resulted in a determination of immediate jeopardy. Notice of the immediate jeopardy (IJ) was given to the Administrator on [DATE] at 6:19 PM. An acceptable plan of correction (P[NAME]) was received from the Administrator on [DATE] at 6:35 PM. After verification of the implementation of the plan of correction (P[NAME]), the immediate jeopardy (IJ) was abated on [DATE] at 6:35 PM. d) The facility's plan of correction for the immediate jeopardy [DATE], (YEAR) Administrator immediately removed the identified agency LPN from the floor at 6:30pm on (MONTH) 11, (YEAR). Staffing was immediately adjusted accordingly to meet resident needs. All residents of the facility have the potential to be effected. No residents of the facility have experienced any negative outcome. A list of all Agency Employee's was immediately complied by the CED, on (MONTH) 11, (YEAR) at 7:03pm. All agency Employee's identified were immediately notified by the Administrator/Designee to come to the Center to complete the WV Cares Application to initiate the background check process. Agency personnel who have not submitted their application and completed their fingerprints will not be placed on the schedule to work. Administrator/Designee will re-educate Human Resource Manager/Designee on the WV Clearance for Access (WV Cares) and Employment Screening System as required by the Centers for Medicare and Medicaid Services (CMS) with a post- test to validate understanding. Administrator/Designee will complete a review of New Hire/Agency personnel files on (MONTH) 11, (YEAR) to ensure an application and fingerprints have been initiated prior to new hire beginning work in the Center to ensure completion of the WV Cares with confirmed eligibility to work in the Center for 30 days. Trends identified will be reported by the Administrator/Designee monthly to the Quality Improvement Committee for any additional follow-up until the issue is resolved and randomly thereafter as determined by QIC. e) After removal of the immediate jeopardy, a deficient practice remained at a scope and severity of [NAME] for this requirement for failure to ensure a nurse aide maintained a current registration. A review of the personnel file for Nurse Aide (NA) #83, on [DATE] at 3:15 PM, revealed this employee did not have a current Nurse Aide Registration. NA #83's registration had expired on [DATE]. An interview with Corporate RN #87, on [DATE] at 3:20 PM revealed the facility had obtained the nurse aide results after requested by the surveyor. A current registration was not present prior to surveyor intervention. NA #83 was hired by the facility on [DATE]. A review of the time records revealed the employee worked after his/her NA registration expired on : [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. | 2020-09-01 |
| 1595 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 641 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for two (2) of twenty (20) residents reviewed during the annual Long Term Care Survey Process (LTCSP). Eight (8) of Resident #14's MDS assessments did not accurately reflect the resident's contractures that were present on admission. Additionally, Resident #56's admission MDS with an ARD of 06/29/18 was not completed in the area of cognitive status. Resident identifiers: #14 and #56. Facility census: 61. Findings included: a) Resident #14 Review of Resident #14's medical records found the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Further review found a physical therapy evaluation, dated 02/27/17, identified Resident #14 had contractures of the bilateral hips, knees, and ankles. Review of the eight (8) MDSs completed since the resident's admission on 02/25/18, found the MDSs did not accurately reflect the resident's multiple contractures which were present at the time of admission. An interview on 07/11/18 at 3:30 p.m. with the Director of Nursing (DoN) and the Nursing Home Administrator (NHA) confirmed the eight (8) MDSs completed for Resident #14 since admission were inaccurate in the area of contractures. b) Resident #56 Review of the resident's admission minimum data set (MDS), with an assessment reference date (ARD) of 06/29/18, found the cognitive section of the MDS was not completed. Further record review found the resident had capacity to make medical decisions. At 10:57 AM on 07/10/18, the Social Services Director (SSD) said the cognitive questions on the admission MDS should have been completed for the resident. The SSD said, I was on vacation that week so I guess no one did that section. On 07/12/18, when advised of the incomplete MDS, the NHA stated she was aware of the situation. | 2020-09-01 |
| 1596 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 655 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop and implement baseline care plans within forty-eight (48) hours of admission for three (3) of twenty (20) new admissions whose care plans were reviewed. Resident #208's baseline care plan failed to include the resident's immediate care and needs for end stage [MEDICAL CONDITION], which required [MEDICAL TREATMENT] treatments three (3) days a week. Resident #108's baseline care plan failed to address the resident's immediate activity, toileting, and pain needs. Resident #52's baseline care plan failed to include this resident's immediate needs for isolation precautions. Resident Identifiers: #208, #108, and #52. Facility census: 61. Findings included: a) Resident #208 Medical record review on 07/10/18 at 10:07 AM found the resident's baseline care plan addressing her immediate needs was not completed within forty-eight (48) hours of her original admission on 06/27/18, nor was there evidence of an updated care plan after readmission on 06/30/18. It was not completed until 07/09/18. During an interview on 07/10/18 11:43 AM, the Director of Nursing (DON) verified the baseline [MEDICAL TREATMENT] care plan for Resident #208 was not completed within forty-eight (48) hours of her admission on 06/27/18 and re-admission date of [DATE]. b) Resident #108 1. A review of the resident's medical record on 07/10/18, revealed the 07/06/18 admission assessment identified the resident was continent of bowel. The assessment further identified the resident used the bathroom or bedpan for toileting. The resident was also assessed as being continent of urine with urgency and toileting method of commode or bedpan. On 07/10/18 at 11:20 AM, Nurse Aide (NA) #43 stated Resident #108 knew when she needed to go to the bathroom and would ask for a bedpan. The initial care plan, dated 07/07/18, noted Resident #108 was incontinent with an intervention to provide incontinence care. The care plan did not reflect the assessment of being continent of bladder and bowel function on admission, or initiate modalities to maintain Resident #108's bowel and bladder function 2) During the initial tour on 07/09/18 at 11:10 AM, Resident #108 complained that her left wrist was extremely sore. Her wrist was red and swollen and the resident protected the extremity with any movement. A review of the initial pain assessment, dated 07/06/18, evaluated pain in the resident's left wrist that was described as sharp and sore and was made worse with movement. The pain assessment also noted that Resident #108 was not satisfied with the current level of pain. A review of the resident's baseline care plan dated 07/07/18, revised on 07/10/18, revealed no focus area of wrist pain, nor goals and interventions related to the pain in her wrist area. c) Medical record review on 07/09/18, revealed Resident #52 had received medication for [MEDICAL CONDITION] and should be isolated by contact precautions. During an interview on 07/09/18 at 11:08 AM, Resident #52 revealed she was having problems with diarrhea. An interview with the Administrator on 07/10/18 at 04:45 PM, verified that Resident #52 had been in isolation at the time the survey began, but it was discontinued on 07/10/18. A review of the resident's baseline care plan found it did not include any evidence the resident had a [DIAGNOSES REDACTED]icile infection when admitted , or that isolation precautions were in place from the time of admission through 07/10/18. | 2020-09-01 |
| 1597 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 657 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, the facility failed to ensure Resident #43 was offered/given the opportunity to attend and/or participate in her care planning process. This was true for one (1) of twenty (20) residents whose care plans were reviewed. Resident identifier: #43. Facility census: 61. Findings included: a) Resident #43 At 12:14 PM on 07/09/18, Resident #43 said she did not think she had been invited to attend any care plans. She said she would attend the meeting if invited. Record review found the resident was admitted to the facility on [DATE]. Review of the most recent quarterly, minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/14/18, found the resident's score on the Brief Interview for Mental Status (BIMS) was 14, indicating she was cognitively intact. Further review of the notes in the resident's electronic medical record found care plan meetings were held on 06/12/18 and 03/20/18. The notes indicated the resident's responsible party was invited to the care plan on 06/12/18, but did not attend. On 03/20/18, the care plan note indicated the resident's responsible party attended the meeting via telephone. At 8:59 AM on 07/11/18, the Social Service Director (SSD) said that she was unable to find any evidence to substantiate the resident was invited to her care plan meetings. She said the resident had a court appointed medical guardian. The SSD said she was aware the resident's BIMS score was 14 indicating the resident was cognitively intact. The SSD was unable to provide evidence the resident was unable to participate in her care planning process. At 9:49 AM on 07/12/18, the administrator said she was aware the resident was not invited to participate and or attend her care plan meetings. | 2020-09-01 |
| 1598 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 684 | E | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, responsible party interview, observation, record review, policy review, and staff interview, the facility failed to identify and provide needed care and services that were resident centered in accordance with resident preferences, goals for care and professional standards of practice to meet each resident's physical, mental, and psychosocial needs for five (5) of twenty (20) residents reviewed. The facility failed to follow up with Resident #4's attending physician when the resident's cardiologist recommended medication changes. The facility failed to coordinate services of a Hospice agency for Resident #31. Resident #56 did not receive medications ordered by the facility physician. Resident #46 failed to have completed neurological checks after falls on three separate occasions. The facility failed to follow physician's orders [REDACTED].#260. Resident identifiers: #4, #56, #31, #46, and #260. Facility census: 61. Findings include: a) Resident #4 Record review found the resident was admitted to the facility from her home on 03/29/18. Review of medical information from a hospital, dated 02/26/18, and supplied to the facility upon admission found the resident's admitting [DIAGNOSES REDACTED].>- Chronic ischemic [MEDICAL CONDITION], - [MEDICAL CONDITION], - Hypertension, - [MEDICAL CONDITION] infarction, - [MEDICAL CONDITION]. Past surgeries included: - Cardiac pacemaker placement, - coronary artery angioplasty, and - coronary artery bypass graft. On 05/23/18, the resident kept a previously scheduled visit to a local cardiologist. The cardiologist provided a written consult of the visit and ordered: Stop [MEDICATION NAME] 30 milligrams (mg) twice daily and start [MEDICATION NAME] CD 120 mg daily. Start [MEDICATION NAME] 20 mg once daily. Weigh self-daily. First thing in the morning following restroom use. Record weights daily. Low sodium diet. 2,000 mg/day guideline. ([MEDICATION NAME] is a drug that is used for treating chest pain ([MEDICAL CONDITION]), high blood pressure, and abnormal heart rhythms. [MEDICATION NAME] CD is an extended release formulation.) ([MEDICATION NAME] is a diuretic used rid the body of excess water from the body. It can be used to treat high blood pressure, [MEDICAL CONDITION], and other conditions.) At the time of the cardiologist visit on 05/23/18, the resident was receiving the following medications: [REDACTED] - [MEDICATION NAME] 10 mg., at nighttime, for a [DIAGNOSES REDACTED].>- Aspirin 81 mg., daily, for a [DIAGNOSES REDACTED]. - [MEDICATION NAME] 20 mg., daily, for depression, - [MEDICATION NAME] 30 mg., twice a day, for hypertension, - [MEDICATION NAME], 15 mg., daily for Hypertension - [MEDICATION NAME] 25 mg., daily, for Hypertension - [MEDICATION NAME] 1,000 mg. SR, daily, for diabetes Mellitus, - [MEDICATION NAME] 30 units, at bedtime, for Diabetes Mellitus, - Xarelto 20 mg, daily, [DIAGNOSES REDACTED]. - [MEDICATION NAME] 100 mg., daily, for hypertension, - Trulicity 0.75 mg./0.5 ML, daily, for diabetes Mellitus. On 06/05/18, the facility sent the resident to the hospital for complaints of chest pains. The resident was admitted to the hospital and returned to the facility on [DATE]. The resident's hospital discharge summary, dated 06/07/18, noted the discharge [DIAGNOSES REDACTED]. At 3:39 PM on 07/10/18, the Corporate Registered Nurse Consultant (CRNC) #87, verified the facility did not follow the guidelines/medication changes specified by the cardiologist on 05/23/18. The [MEDICATION NAME] was not increased, the resident did not receive [MEDICATION NAME], and daily weights were not obtained. CRNC #87 was unable to provide verification the facility physician was aware of the recommended medication changes specified by the cardiologist on the 05/23/18 visit. CRNC #87 said the doctor usually signs the consults from physician visits to indicate he is aware of the recommendations. CRNC #87 reviewed the nursing notes for 05/23/18 and found no evidence the physician was made aware of the recommendations. CRNC #87 reviewed the physician's notes and found no evidence the physician was aware of the recommended medication changes and found no evidence to support the physician was aware and chose not to follow the recommendations. Further review of the Medication Administration Record, [REDACTED]. At 10:03 AM on 07/12/18, the Director of Nursing (DoN) reviewed the information and provided no further documentation. b) Resident #31 The resident's responsible party (RP) was interviewed by telephone on 07/09/18 at 2:03 PM. The RP was aware the resident was receiving Hospice Care at the facility, but was not clear about what services the Hospice provided. She said that the Chaplin had called on at least 2 or 3 occasions, but she had never spoken to any of the nurses. They said they would touch base with me for updates, but they never did. I would just like a report on how everything is going. The RP said that she had been ill herself and had not been able to visit the facility as often as she would like. Review of the medical record found a physician's orders [REDACTED]. Further review of the resident's medical record, kept at the nurses' station, found a section entitled Hospice with no information present from the Hospice company. At 3:00 PM on 07/11/18, CRNC #87 said she would go to medical records to get some notes from the Hospice company. She returned with a folder containing the last Hospice notes, which were from (MONTH) (YEAR). At 3:05 PM on 07/11/18, Registered Nurse (RN) #54 was unable to provide any documentation from the Hospice Company. She said, They talk to us but don't leave us anything. She said the Hospice nurse visits weekly, but she was unsure of the day. The Nursing Assistant's come 2 days a week, I think Tuesday and Thursday, but I don't know what they actually do. They don't leave anything like a report, but they make us sign a paper saying they were here. I believe they do take care of controlling the resident's pain and making recommendations for that. At 3:37 PM on 07/11/18, CRNC #87 verified the last documentation from Hospice was a nursing note from 03/22/18. She said she was continuing to look for more notes. During an interview about the Hospice services at 4:00 PM on 07/11/18, Registered Nurse (RN) #40 and Licensed Practical Nurse #7, said they had not worked at the facility very long and they did not really know what the Hospice company did or exactly when they visited. Neither employee knew where the Hospice notes were kept. At 8:20 AM on 07/12/18, the resident's Nursing Aide (NA) #9, said she heard the Hospice NAs come on Tuesday and Thursday, but she did not know that for sure. She really did not know what the NAs did when they came. In an interview with the resident's nurse, Licensed Practical Nurse (LPN) #75, at 8:25 AM on 07/12/18, the nurse said, Hospice probably has set days for which they visit, but I am not sure of what they exactly do when they are here. At 9:53 AM on 07/12/18, the DoN said she had not observed the specific care provided by the Hospice nurse or the NAs. I am going to look for more information. At 9:45 AM on 07/12/18, the Administrator said she had already contacted the Hospice company and was taking care of the issues. c) Resident #56 Record review found the resident was admitted to the facility on Friday, 06/22/18. Review of the Medication Administration Record [REDACTED] - [MEDICATION NAME] 50 mg. at 8:00 AM and 8:00 PM for Depression, - Atorvastatin 80 mg at 8:00 PM for [MEDICAL CONDITION], - Carvedilol 6.25 mg, at 8:00 AM and 8:00 PM for Hypertension, - [MEDICATION NAME] 7.5 mg. at 8:00 AM (a blood thinner), - Entecavir 0.5 mg., at 8:00 AM for infection (Entecavir is an [MEDICAL CONDITION] medication used to treat long term B [MEDICAL CONDITION].), - Multivitamin daily at 8:00 AM, - Tylenol 650 mg. as needed, every 6 hours, and - [MEDICATION NAME] 150 mg., at 6:00 AM, 2:00 PM and 9:00 PM for Pain. - [MEDICATION NAME] 5/325 every 6 hours as needed (pain medication). At 1:07 PM on 07/10/18, the CRNC #87 confirmed the resident was admitted to the facility at 11:30 PM on 06/22/18. After review of the MAR, CRNC #87 confirmed the resident only received her Multivitamin and her as needed (PRN) [MEDICATION NAME] 5/325 on 06/23/18. The resident did not receive any of the other ordered medications until 06/24/18. CRNC #87 said she would call the nurse to see why the other medications were not given. CRNC #87 said most likely the medications were not available to administer. At 11:02 AM on 07/12/18, the DoN verified all the resident's medications ordered by the physician were not given on 06/23/18 as ordered because they were not at the facility. The DoN provided no evidence the physician was notified the medications were not available. d) Resident #46 Review of Resident #46's medical records found this resident had three (3) falls requiring neurological assessments to be completed due to the fall being unwitnessed and/or the resident hit her head. The falls occurred on 03/09/18 at 1:15 AM, 03/25/18 at 4:30 AM, and 05/29/18 at 4:40 PM Review of the facility's neurological policy found it directed, Neurological assessments will be performed as indicated or ordered. When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessments will be performed: every 30 minutes for two (2) hours then every hour for four (4) hours and then every four (4) hours for 24 hours. Review of the neurological examinations for the falls requiring completion of neurological assessments found all were incomplete and/or blank for vital signs, evaluation for level of conscious and/or pupil response. During an interview on 07/10/18 3:43 pm, the DoN verified the neurological assessments for Resident #46 on 03/09/18, 03/25/18 and 05/29/18 were all incomplete. e) Resident #260 During an observation on 07/09/18 at 1:53 PM, Resident #260's oxygen liter flow was set on 2.5 liters (L) and delivered via nasal cannula (NC). When asked what rate it normally ran, the Resident #260 replied it should be on 3L. Review of physician's orders [REDACTED]. The resident's admitting [DIAGNOSES REDACTED]. -Pneumonia -Pulmonary [DIAGNOSES REDACTED] (a yeast-like fungus, resulting in tumors in the lungs and sometimes spreading) -Malignant Neoplasm of the Bronchus and Lung -Heart Failure -[MEDICAL CONDITION] During an interview on 07/10/18 at 3:33 PM, the DoN confirmed the oxygen rate was still at 2.5 [MI] She agreed it was set on 2.5 L not 3 L as ordered. She stated that she had looked at it that morning and thought it was correct. | 2020-09-01 |
| 1599 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 689 | K | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the reported allegations of elopement to the nursing home program, and review of facility policy, the facility failed to provide an environment free from accident hazards over which the facility had control. Secure care equipment failed to function properly which had the potential to allow a resident, utilizing the secure care equipment, to leave the facility without staff knowledge. Once the door was opened by a visitor, a resident, or anyone not wearing a secure care alarm, any resident with a secure care alarm could exit the building without activating the alarm. Resident #34 was observed attempting to leave the facility when another resident exited the building. No alarm sounded although the resident had secure care devices on her ankle and wheelchair. Testing of the system found it failed to activate an alarm when a resident wearing a secure care device went through the door when opened by a visitor or other person not wearing a device. Further investigation found an incident when a former resident, Resident #58, had exited the facility while the door was held open by another resident. The report regarding that incident noted, Equipment will be tested , . The transmitter was tested and was working properly according to the immediate action taken. However, the investigation did not indicate if the testing was done when the door was opened or closed. After consultation with the State office a determination of immediate jeopardy was made based on the facility's failure to ensure the secure alarm system was working properly to prevent residents with secure care systems from exiting the facility without staff knowledge. The facility was previously aware of the elopement of Resident #58 on 05/24/18. This incident should have alerted the facility the secure care system was not operating properly. The facility NHA was notified of the immediate jeopardy on 07/11/18 at 12:05 PM The facility provided an acceptable plan of correction. After verifying implementation of the plan, the immediate jeopardy was abated on 07/11/18 at 12:15 PM This practice had the potential to affect five (5) of five (5) residents with a secure care system. Resident identifiers: #2, #38, #34, #37, and #45. After removal of the immediate jeopardy, deficient practices remained at a scope and severity of E. A random opportunity for discovery found the facility failed to ensure the environment over which it had control was free from accident hazards for Resident #4, who fell outside the facility while smoking. A cabinet was unlocked in the shower room creating a potential for more than an isolated number of residents to be exposed to a hazardous chemical. Facility census: 61. Findings included: a) Resident #34 On the morning of 07/10/18, at approximately 10:30 AM, observations found Resident #34 attempting to leave the facility when another resident, without an alarm system, was exiting the building. No alarm sounded at that time. At the time of the incident, the surveyor was unaware Resident #34 was wearing a secure alarm system. The surveyor was alerted to the incident when the male resident was cursing Resident #34, telling her to get back into the building. Licensed Practical Nurse, #52 intervened and assisted Resident #34 back inside the building. Review of the resident's medical record at 8:30 on 07/11/18, found a ninety-eight (98) year old female resident admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's current care plan found a focus/problem of, Resident is at risk for elopement related to Cognitive Loss/ Dementia, dated 09/08/16. The goal associated with the focus/problem: Resident will not attempt to leave the facility without an escort. Interventions included: Secure care device to maintain safety, dated 10/26/17. On 04/29/18, this intervention was revised to include, Utilize and monitor security bracelet left ankle and left side of wheelchair per protocol. At 9:30 AM, on 7/11/18, LPN #52 was asked about the observation on Resident #34 occurring on 07/10/18. LPN #52 said the resident would try to exit the facility because she thought she needed to get her kids or get her mother and father. When asked why the secure care alarm did not activate yesterday, LPN #52 said the other resident had already opened the door. The other resident did not have a secure care alarm bracelet because he was allowed to go outside, unattended. Since the door was open, she could get out. LPN #52 said the door did not alarm if someone else already had it opened. The resident is smart enough to know she could make a beeline to the front door because the door was opened. At 10:00 AM on 07/11/18, investigation found Resident #34 had two (2) secure care alarm devices - one device was on her ankle and one device attached to her wheelchair. The alarm system of the front door was tested on [DATE] at 10:05 AM, by the NHA and the Maintenance Supervisor (MS). When a secure care bracelet was held by the MS, within approximately two to three feet of the front door, the door locked. However, once the MS stepped back from the door, the door could be opened. When the door was held open by the surveyor, the MS was able to pass through the front doors, while holding the secure care bracelet, without the alarm sounding. The MS said the alarm system should always activate when any resident with a secure care system passed through open doors. This had the potential to affect Residents #2, #38, #34, #37, and #45. At 11:05 AM on 07/12/18, the NHA said, As for the wander guard system we just had random checks in place that were not documented. It was just verbal saying the doors were checked. I have changed that now. b) Review of the facility reports of elopement to the nursing home program Further investigation of the facility's reportable allegations of elopement to the nursing home program found another resident, Resident #58, (now discharged ) had exited the facility on 05/24/18. The facility's investigation found, (Name of resident) and another male resident were found taking a walk outside of the facility back by the employee smoking area. (Name of Resident) does not have capacity and currently has a secure care transmitter in place. (Name of Resident) exited the facility while the door was held open by another resident who is alert/oriented and does not have a secure care transmitter. No injury occurred to (Name of Resident) or the other Resident. (Name of resident) re-entered the building without difficulty or issue. Equipment will be tested . alert/oriented resident will be educated. The transmitter was tested and was working properly, according to the immediate action taken. At 10:32 AM on 07/11/18, the NHA said she did not know how staff tested the doors after the elopement on 05/24/18. She could not verify the door was tested after being opened. Observation with the NHA found a secure care system on the front door, the patio door, leading to the staff smoking area and the service entrance doorway. At 10:50 AM on 7/11/18, the NHA said she called the Secure Care Company. She said, It is a fluke and Secure Care is on the way. The NHA verified the Secure Care Alarm System was supposed to alarm even if the door was already opened when any resident wearing a secure care alarm passed through the open door. c) Review of the facility's policy for, Patient Security Bracelet. The facility's policy, effective 05/01/16 included, Patient security bracelets (e.g., wander guard) will be inspected per manufacturer's recommendations but at a minimum of: Every shift for placement, and Daily for function d) Notification of immediate jeopardy At 12:05 PM on 07/11/18, the NHA was notified in writing the immediate jeopardy was being called due to the failure of the Secure Care Alarm System to function properly. The NHA was also informed the facility should have known about the malfunctioning system on 05/24/18 when an actual elopement occurred during which time the resident was wearing a secure care bracelet. e) Plan of correction Doors 1. All doors were manned by facility staff at 10:55AM to ensure no resident exited the building who were wearing secure care equipment. The Administrator (NHA) contacted the secure care health systems at 10:47AM to request tech support for secure care equipment failure. Call received from secure care tech at 11am to review step by step process of resetting the master code for the secure care system with the Maintenance Director. At 11:20am the secure care function was reset by the Maintenance Director and all doors were functioning appropriately with the door opened or closed when a resident with a secure care transmitter in place was trying to exit. Residents #2, #34, #38, #37, #45 have not experienced any negative outcomes. Resident #58 no longer resides in the facility. 2. All residents of the facility who have secure care transmitter in place have the potential to be affected. The Maintenance Director/designee checked all residents who have secure care transmitter bracelet to ensure proper functioning with or without the code entered and door was opened or closed on 7/11/18 at 2:16pm with no additional corrective action required. 3. The NHA/designee will reeducate all staff beginning 7/11/18 regarding ensuring the safety of residents with the secure guard wander system including the functioning of the secure care system with the door opened or closed and notifying Maintenance and NHA immediately if the system does not function appropriately with a posttest to validate understanding. Staff not available will be provided reeducation and complete posttest upon return to work by the NHA/designee. New staff will receive education and complete posttest during orientation by the NHA/designee. The maintenance director/designee will check the secure care system functioning daily across all shifts X 2 weeks including weekends then three times a week for two weeks then randomly thereafter to ensure the secure care alarm are function properly when the doors are opened and closed. 4. Trends identified will be reviewed by the Maintenance Director/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issue is resolved and randomly thereafter as determined by the QIC committee. At 12:05 PM on 07/11/18, the immediate jeopardy was abated after verifying staff were posted at each exit door. The secure care system was repaired with technical support of the alarm company and the doors were repaired at 11:20 AM on 07/11/18. After removal of the immediate jeopardy, deficient practices remained at a level of E. f) Resident #4 At 11:25 AM on 07/09/18, Resident #4 said she fell the first night she came to the facility. She said she went outside to smoke, alone. She said she was not used to riding in a wheelchair, it was dark, and she was not familiar with the place and somehow, her wheelchair got stuck on the sidewalk and fell . She said an ambulance driver came along and found her. They didn't know I had fallen. She said she went to the hospital. I had a nasty black eye, broke some bones in my face and had a big knot on my head. They thought I broke my nose. After that I wasn't allowed to smoke alone again. Medical record review found the resident was admitted to the facility on [DATE]. Review of the nursing notes found the following entries: - 03/29/2018 at 10:26 AM, Admission Note: Resident admitted /readmitted to 220-[NAME] Arrived by private car and wheelchair. Information upon admission obtained from patient family and/or significant other chart. Reason for admission is Long Term Care. A Braden score of 20.0 and Fall Risk score of 6.0 were obtained as part of this assessment. Call bell placed within reach. Physician notified/orders verified: Yes. See nursing admission assessment (UDA) for detailed clinical findings. 03/29/18 at 8:54 PM, Resident fell while outside smoking, staff notified by EMS (Emergency Medical Services) staff bringing in new resident, EMS had already gotten resident up and placed in wheelchair and brought in building. Resident had notable swelling to left eye and forehead. Abrasions to left forehead, left eye and left nose. Neuro's (neurological check) intact. Patient requested to go to Hospital. (Name of physician) and Niece notified. 03/29/18 at 11:30 PM, Report called in from (name of local hospital) stating Resident was being released that CT (computerized tomography) was negative resident dx (diagnosis) was facial fracture and hematoma to left forehead Review of the hospital discharge summary, dated 03/29/18, found the resident had a traumatic hematoma of her forehead and a closed [MEDICAL CONDITION] bones. The smoking assessment completed on 03/29/18 at 10:26 AM, noted the resident did not use oxygen, did not have dementia, and independent smoking was allowed. According to the assessment, the resident was able to demonstrate the location of smoking area, able to hold, light and discard appropriately. Review of the risk management system found the resident fell on [DATE] at 8:30 PM Resident was outside smoking when EMS came to drop off a new admit and found resident on side walk. EMS picked resident up off of sidewalk and brought her inside in her wheelchair before alerting staff. Nurse assessed patient after being alerted of fall. Abrasions noted to left side of nose, left eye, left forehead and left cheek. Wounds cleansed with normal saline and [MEDICATION NAME] placed to avoid infection, resident alert and oriented stated she was trying to turn around to come back in and her wheelchair went off side walk and got stuck, she attempted to get herself unstuck and fell on left side of face. No other injuries noted. Resident requested to be sent to ER A second smoking assessment, completed on 03/30/18 at 4:22 PM (the day after the first assessment), noted the resident lacked capacity and lacked safety awareness with history of falls and was not allowed to smoke. This assessment noted the resident had dementia, poor memory and was unable to demonstrate the location of the designated smoking area. At 2:32 PM on 07/10/18, the Director of Nursing (DoN) was unable to provide any further information related to the resident's fall while smoking. She was unable to provide documentation the facility assessed the resident for the ability to physically transport herself to and from the smoking area. At 10:02 AM on 07/12/18, the DoN was again asked if she had any information to validate the resident was thoroughly assessed for safe smoking upon admission. No further information was provided. c) An observation of the 100 Hall shower room, on 07/10/18 at 7:35 AM, revealed the wall cabinet containing a bottle of Virex, a hazardous item, was unlocked. This was an area accessible to residents. According to the Material Safety Data Sheet (MSDS), Virex is a corrosive agent capable of causing permanent damage to the eyes and skin and is an irritant to the respiratory tract. It also noted Virex is capable of causing permanent damage to the gastrointestinal tract if swallowed. An interview with Nurse Aide (NA) #43, on 07/10/18 at 07:40 AM, verified the cabinet was unlocked and the side containing the Virex could not be locked with the key present. Additionally, there were keys hanging that did lock the left side of the cabinet, making locking and unlocking the left side accessible to anyone. An interview with the NHA, on 07/10/18 at 8:50 AM revealed that cabinets containing hazardous items should be locked and keys not readily accessible to anyone in the shower room. | 2020-09-01 |
| 1600 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 690 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, staff interview, and record review, the facility failed to ensure one (1) of two (2) residents who was continent of bowel and bladder on admission, received care and services to maintain continence. Resident identifier: #108. Facility census: 61. The findings included: a) Resident #108 During a random observation on 07/09/18 at 1:00 PM, Resident #108 complained she was not assisted to the bathroom and she was wet. With assistance of staff, it was verified that the resident had a brief on and it was soiled. In an interview on 07/09/18 at 1:07 PM, Nurse Aide (NA) #43 stated the resident knew when she needed to go to the bathroom and would ask for the bedpan. A review of the resident's medical record on 07/10/18, revealed an admission assessment dated [DATE], noting Resident #108 was continent of bowel on admission. The assessment further stated the resident used the bathroom or bedpan for toileting. The assessment also identified the resident was continent of urine with urgency and used the commode or bedpan. On 07/10/18, at 11:15 AM, accompanied by Center Nurse Executive #74, NAs responsible for the care of Resident #108 were interviewed. When NA #85 was question about the toileting practices and care for Resident #108, the NA responded, I do not know the answer. During an interview on 07/10/18 at 11:21 AM, NA #25 said she, had her a couple of days ago and she had a brief on and was not taken to the toilet. At 11:20 AM on 07/10/18, NA #43 stated Resident #108 knew when she needed to go to the bathroom and would ask for a bedpan. The initial care plan, dated 07/07/18, identified Resident #108 as incontinent with an intervention to provide incontinence care. The care plan did not reflect the admission assessment that identified the resident as continent of bladder and bowel function, nor were modalities to maintain or improve Resident #108's bowel and bladder function identified. | 2020-09-01 |
| 1601 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 697 | H | 0 | 1 | 5JPY11 | **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 Resident #14 received pain management consistent with his needs and physician's orders [REDACTED]. Resident #14 said he had to beg for pain medication and expressed anger at the staff. Due to a transcription error, Resident #14's pain medication ([MEDICATION NAME]) was given on an as needed (PRN) basis, although the physician's orders [REDACTED]. The failure to ensure the resident received adequate pain management was determined to be actual harm, both physical and psychosocial. Resident identifier: #14. Facility census: 61. Findings included: a) Resident #14 During an interview with Resident #14 on 07/09/18 at 11:30 a.m., he stated, I am hurting all over. A staff nurse was immediately notified of the resident's complaint of pain. On 07/10/18 at 10:45 a.m., when asked about his pain he said, I don't know why I can't get my pain medication. I had it four (4) times daily and then it was increased to six (6) times a day when I was having pain in my suprapubic area. I am supposed to get it four (4) times a day now and I can only get it if I beg for it. The resident expressed anger at the staff and referred to them in a derogatory manner. On 07/10/18 at 11:40 a.m., review of Resident #14's physician's orders [REDACTED]. This was to be given around the clock. Prior to (MONTH) 14, (YEAR), the resident had received [MEDICATION NAME] six (6) times a day as he stated during the interview. Review of the resident's medication administration records (MAR) found from 06/14/18 until the end of June, the resident received [MEDICATION NAME] 4 times a day, around the clock. He received it at 12 midnight, 6:00 AM, 12:00 noon, and 6:00 PM until July, when the medication was entered into the computer as a PRN medication in error. Review of Resident #14's Medication Administration for (MONTH) (YEAR), found beginning on 07/01/18, the pain medication [MEDICATION NAME] was only administered on as needed basis (PRN). Record review also identified this resident's [DIAGNOSES REDACTED]. He was essentially bedridden, dependent on staff for activities of daily living other than eating, and had impairment of functional range of motion in both upper and lower extremities. Observations noted he had contractures of his hips and knees. During an interview with the Director of Nursing (DON) on 07/10/18 3:43 pm, verified the order for Resident #14's pain medication ([MEDICATION NAME]) had been inaccurately entered into the computer. She confirmed the resident had not received his pain medication as ordered since 06/30/18, causing Resident #14 to experience pain. The failure to ensure the resident received pain medication as ordered, resulted in inadequate pain management and caused the resident to be angry. These findings were determined to be physical and psychosocial harm. | 2020-09-01 |
| 1602 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 698 | E | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility's policy for care and treatment for [REDACTED].#208 received ongoing assessment of her condition before and after [MEDICAL TREATMENT] to monitor for complications. The facility also failed to ensure there was ongoing communication and collaboration with the [MEDICAL TREATMENT] facility. Furthermore, the facility failed to implement its own policy which was consistent with standards of practice. This was true for one (1) of one (1) resident reviewed for [MEDICAL TREATMENT]. Resident identifier: #208. Facility census: 61. Findings included: a) Resident #208 Review of medical records found Resident #208 was originally admitted to the facility on [DATE] and then was readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Further review found the resident had a arteriovenous (A-V) fistula in her upper left arm and an external [MEDICAL TREATMENT] catheter in the right [MEDICATION NAME] area (collar bone area). There was no evidence facility staff were monitoring either site. Review of the facility's policy for care and services needed for residents receiving [MEDICAL TREATMENT] included, but not limited to: - the methods of communication between the nursing home and the [MEDICAL TREATMENT] facility including how it would occur, with whom, and where the communication and responses would be documented, - the development and implementation of a coordinated comprehensive care plan(s) that identified nursing home and [MEDICAL TREATMENT] responsibilities, and - provided direction for nursing home staff; and - the development and implementation of interventions, based upon current standards of practice including, but not limited to documentation and monitoring of complications, pre-and post-[MEDICAL TREATMENT] weights, access sites, nutrition and hydration, lab tests, vital signs including blood pressure and medications, the provision of medications on [MEDICAL TREATMENT] treatment days, procedures for monitoring and documenting nutrition/hydration needs, including the provision of meals on days that [MEDICAL TREATMENT] treatments are provided and the assessment, observation and documenting of care of access sites, as applicable, such as: Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow, significant changes in the extremity when compared to the opposite extremity ([MEDICAL CONDITION], pain, redness) and the care needed for the external [MEDICAL TREATMENT] catheter. The facility will use a [MEDICAL TREATMENT] Communication Record before leaving for [MEDICAL TREATMENT] the top portion will be completed by the licensed nurse, which includes the vital signs and the patency of any [MEDICAL TREATMENT] ports (A/V shunts and/or external [MEDICAL TREATMENT] catheters. The [MEDICAL TREATMENT] nurse will complete the form and return to the facility. Upon return from the [MEDICAL TREATMENT] facility the license nurse will review the communication form and evaluate the resident and document. If the [MEDICAL TREATMENT] facility does not return the form the licensed nurse will call the [MEDICAL TREATMENT] facility and asked the form to be completed and faxed to the facility. The external catheter and the A/V shunt should be monitored and evaluated every eight (8) hours or more frequently if complications are suspected. Review of Resident's medical records found Resident #208 had been to [MEDICAL TREATMENT] four (4) times (07/02/18, 07/04/18, 07/06/18, and 07/09/18). There was no evidence the facility was providing meals during [MEDICAL TREATMENT], no communication records, and no evidence the licensed nurses were evaluating the A/V shunt and external [MEDICAL TREATMENT] catheter every eight (8) hours. During an interview on 07/10/18 at 2:15 PM, the Director of Nursing (DoN) verified the [MEDICAL TREATMENT] communication sheets were incomplete or not even done, and there was no documentation of assessments of the A/V shunt and external [MEDICAL TREATMENT] catheter by a licensed nurse every 8 hours. Additionally, the DoN verified the care of Resident #208 had not been coordinated with the [MEDICAL TREATMENT] center. | 2020-09-01 |
| 1603 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 730 | D | 0 | 1 | 5JPY11 | Based on staff interview and employee record review, the facility failed to ensure performance evaluations were completed at least once every 12 months and failed to provide employees with regular in-service education based on the outcome of these reviews. One (1) of four (4) employees reviewed did not receive in-services as required and three (3) of four (4) employees did not have an annual performance appraisal as required. Employees identifiers: #83, #45, #16. Facility census: 61. Findings included: a) Nurse Aide (NA) #83 NA #83's personnel file identified a hire date of 04/06/2016, with the last performance evaluation dated 04/25/17. An interview with the Corporate Registered Nurse (RN) #87 on 07/11/18 at 03:34 PM, verified there was not a more recent performance evaluation than 04/25/17. b) NA #45 The NA #45's personnel file revealed a hire date of 10/10/16. There was no record of a performance evaluation for this employee, only a skills check off sheet dated 02/09/18. There was no in-service record to review. An interview with Corporate RN #87 on 07/11/18 at 3:34 PM verified that there was no performance evaluation or in-service record for this employee. c) NA #16 Review of the personnel file for NA #16 on 07/11/18, revealed a hire date of 04/20/16. The last performance evaluation was completed 04/19/17. An interview with the Corporate RN #87 on 07/11/18 at 4:02 PM verified there was no current performance evaluation for this employee. | 2020-09-01 |
| 1604 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 761 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and manufacturer's guideline review, the facility failed to ensure all multi-use insulin vials were dated when opened to ensure the medication's safety and potency. The 200 Hall medication cart, which was one (1) of two (2) medication carts observed, contained an undated open vial of [MEDICATION NAME]. This was true for one (1) of five (5) vials of insulin in the medication cart and had the potential to directly affect one (1) resident, Resident #45. Facility census: 61. Findings included: a) Resident #45 An inspection of the medication cart on the 200 Hall on 07/12/18 at 9:19 AM, found a multi-dose vial of [MEDICATION NAME] (insulin used to control blood sugar) with no date to indicate when the vial was opened. Licensed Practical Nurse (LPN) #75 was witness to this finding. The medication belonged to Resident #45. When discussed with Corporate Nurse #87 on 07/12/18 at 9:40 AM, she stated she would take care of the matter. The manufacturer's instructions included: In-use [MEDICATION NAME](R) vials 1. Vials must be kept in the refrigerator or at room temperature below 86 F (30 C) for up to 42 days. 2. Keep vials away from direct heat or light. 3. Throw away an opened vial after 42 days of use, even if there is insulin left in the vial . | 2020-09-01 |
| 1605 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 812 | E | 0 | 1 | 5JPY11 | Based on observation and staff interview, the facility failed to ensure food was stored in a manner to prevent food borne illnesses. Outdated food items were present in the walk-in refrigerator in the kitchen. This practice had the potential to affect more than an isolated number of residents. Facility census: 61. Findings include: a) Initial tour of the kitchen Upon entrance to the facility at 11:00 a.m. on 07/09/18, observation of the kitchen with the Dietary Manager (DM) found a dessert identified by the DM as being made with whipped cream cheese and cookies, dated 06/26/18. The DM said the 06/26/18 date was when the item was made. The DM said the dessert should have been discarded within seven (7) days - 07/03/18. A second observation found a container of sour cream with a manufacturer's stamped date of discard - 07/07/18. The DM said she would throw away the dessert and the sour cream. At 11:20 a.m. on 07/12/18, the Administrator said she was aware of the findings and provided no further comment or information. | 2020-09-01 |
| 1606 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 835 | F | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, record review, policy review, 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, mental, and psychosocial well-being of each resident. The facility received an immediate jeopardy when the system did not alarm to alert staff wandering residents wearing devices were leaving the facility. On 05/24/18, another resident (now discharged ) with a secure care alarm, was found outside the facility without facility knowledge. On 07/11/18, Resident #34, who had two secure care alarm devices was able to exit the front door of the facility without the alarm sounding. The failure of the facility to take corrective actions after the 05/24/18 occurrence, resulted in continuation of the failure of the secure care alarm to work effectively. This practice had the potential to affect five (5) of five (5) residents with a secure care alarms. Resident identifiers: #2, #38, #34, #37, and #45. Facility census: 61. Findings included: a) Resident #34 On the morning of 07/10/18, at approximately 10:30 AM, observations found Resident #34 attempting to leave the facility when another resident, without an alarm system, was exiting the building. No alarm sounded at that time. At the time of the incident, the surveyor was unaware Resident #34 was wearing a secure alarm system. The surveyor was alerted to the incident when the male resident was cursing Resident #34, telling her to get back into the building. Licensed Practical Nurse, #52 intervened and assisted Resident #34 back inside the building. Review of the resident's medical record at 8:30 on 07/11/18, found a ninety-eight (98) year old female resident admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's current care plan found a focus/problem of, Resident is at risk for elopement related to Cognitive Loss/ Dementia, dated 09/08/16. The goal associated with the focus/problem: Resident will not attempt to leave the facility without an escort. Interventions included: Secure care device to maintain safety, dated 10/26/17. On 04/29/18, this intervention was revised to include, Utilize and monitor security bracelet left ankle and left side of wheelchair per protocol. At 9:30 AM, on 7/11/18, LPN #52 was asked about the observation on Resident #34 occurring on 07/10/18. LPN #52 said the resident would try to exit the facility because she thought she needed to get her kids or get her mother and father. When asked why the secure care alarm did not activate yesterday, LPN #52 said the other resident had already opened the door. The other resident did not have a secure care alarm bracelet because he was allowed to go outside, unattended. Since the door was open, she could get out. LPN #52 said the door did not alarm if someone else already had it opened. The resident is smart enough to know she could make a beeline to the front door because the door was opened. At 10:00 AM on 07/11/18, investigation found Resident #34 had two (2) secure care alarm devices - one device was on her ankle and one device attached to her wheelchair. The alarm system of the front door was tested on [DATE] at 10:05 AM, by the NHA and the Maintenance Supervisor (MS). When a secure care bracelet was held by the MS, within approximately two to three feet of the front door, the door locked. However, once the MS stepped back from the door, the door could be opened. When the door was held open by the surveyor, the MS was able to pass through the front doors, while holding the secure care bracelet, without the alarm sounding. The MS said the alarm system should always activate when any resident with a secure care system passed through open doors. At 11:05 AM on 07/12/18, the NHA said, As for the wander guard system we just had random checks in place that were not documented. It was just verbal saying the doors were checked. I have changed that now. b) Review of the facility reports of elopement to the nursing home program Further investigation of the facility's reportable allegations of elopement to the nursing home program found another resident, Resident #58, (now discharged ) had exited the facility on 05/24/18. The facility's investigation found, (Name of resident) and another male resident were found taking a walk outside of the facility back by the employee smoking area. (Name of Resident) does not have capacity and currently has a secure care transmitter in place. (Name of Resident) exited the facility while the door was held open by another resident who is alert/oriented and does not have a secure care transmitter. No injury occurred to (Name of Resident) or the other Resident. (Name of resident) re-entered the building without difficulty or issue. Equipment will be tested . alert/oriented resident will be educated. The transmitter was tested and was working properly, according to the immediate action taken. At 10:32 AM on 07/11/18, the NHA said she did not know how staff tested the doors after the elopement on 05/24/18. She could not verify the door was tested after being opened. Observation with the NHA found a secure care system on the front door, the patio door, leading to the staff smoking area and the service entrance doorway. At 10:50 AM on 7/11/18, the NHA said she called the Secure Care Company. She said, It is a fluke and Secure Care is on the way. The NHA verified the Secure Care Alarm System was supposed to alarm even if the door was already opened when any resident wearing a secure care alarm passed through the open door. c) Review of the facility's policy for, Patient Security Bracelet. The facility's policy, effective 05/01/16 included, Patient security bracelets (e.g., wander guard) will be inspected per manufacturer's recommendations but at a minimum of: d) Interview with the administrator At 11:05 a.m. on 07/12/18, the administrator said, As for the wander guard system we just had random checks in place that were not documented. It was just verbal saying the doors were checked. I have changed that now | 2020-09-01 |
| 1607 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 842 | D | 0 | 1 | 5JPY12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure Resident #300's medical record was complete and accurate. This was true for one (1) of fourteen (14) medical records reviewed during the Revisit survey to the Long-Term Care Survey completed on 07/13/18. Resident Identifier: #300. Facility Census: 56. Findings included a) Resident #300 1. [MEDICAL CONDITION] A review of Resident # 300's medical record found nursing assessments dated 09/11/18 and 09/18/18 which indicated Resident #300 did not have an ostomy. A review of Resident #300's physician's orders [REDACTED]. An interview with the Director of Nursing (DON) and Corporate Resource Nurse (CRN), concluding at 9:40 a.m. on 09/19/18, confirmed the assessments dated 09/11/18 and 09/18/18 did not accurately reflect that Resident #300 had a [MEDICAL CONDITION] on admission to the facility. 2. Urinary Continence Status A review of Resident # 300's medical record found a nursing assessment dated [DATE] which indicated Resident #300 was always continent of her urine. A review of Resident #300's activities of daily living (ADL) flow sheets since admission to the facility on [DATE] through current, found the resident was always incontinent of her urine. An interview with Resident #300 at 9:00 a.m. on 09/19/18 found that she was incontinent of urine. She stated, I wet myself, I don't know when I have to go. I think my shut off valve is broke. An interview with the DON and CRN concluding at 9:40 a.m. on 09/19/18 confirmed the assessment dated [DATE] was inaccurate related to Resident #300's incontinence status. | 2020-09-01 |
| 1608 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 868 | F | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, policy review, review of staff personnel files, and record review, the facility failed to identify issues with respect to which quality assessment and assurance activities are necessary. The facility received an immediate jeopardy for failure to provide an environment free from accident hazards over which the facility had control. Secure care equipment failed to function properly which has the potential to allow a resident, utilizing the secure care equipment, to leave the facility without staff knowledge. This practice had the potential to affect five (5) of five (5) residents with a secure care wandering device. Resident identifiers: #2, #38, #34, #37, and #45. The facility received a second immediate jeopardy for failure to ensure two (2) of four (4) direct care staff were screened for a history of abuse, neglect, exploitation and or any applicable criminal activity that would identify the individual as unfit to work in a long term care facility. This practice had the potential to affect all residents residing at the facility. Employee identifiers #64 and #7. In addition the facility failed to ensure the required staff members attended the quarterly meetings of the Quality Assurance (QA) Committee. This practice had the potential to affect all residents residing at the facility. Facility census: 61. Findings included: a) An immediate jeopardy existed when the facility's secure care alarm failed to alert staff when a resident wearing a secure care device was able to go through the main door. 1. Resident #34 On the morning of 07/10/18, at approximately 10:30 AM, observations found Resident #34 attempting to leave the facility when another resident, without an alarm system, was exiting the building. No alarm sounded at that time. At the time of the incident, the surveyor was unaware Resident #34 was wearing a secure alarm system. The surveyor was alerted to the incident when the male resident was cursing Resident #34, telling her to get back into the building. Licensed Practical Nurse, #52 intervened and assisted Resident #34 back inside the building. Review of the resident's medical record at 8:30 on 07/11/18, found a ninety-eight (98) year old female resident admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's current care plan found a focus/problem of, Resident is at risk for elopement related to Cognitive Loss/ Dementia, dated 09/08/16. The goal associated with the focus/problem: Resident will not attempt to leave the facility without an escort. Interventions included: Secure care device to maintain safety, dated 10/26/17. On 04/29/18, this intervention was revised to include, Utilize and monitor security bracelet left ankle and left side of wheelchair per protocol. At 9:30 AM, on 7/11/18, LPN #52 was asked about the observation on Resident #34 occurring on 07/10/18. LPN #52 said the resident would try to exit the facility because she thought she needed to get her kids or get her mother and father. When asked why the secure care alarm did not activate yesterday, LPN #52 said the other resident had already opened the door. The other resident did not have a secure care alarm bracelet because he was allowed to go outside, unattended. Since the door was open, she could get out. LPN #52 said the door did not alarm if someone else already had it opened. The resident is smart enough to know she could make a beeline to the front door because the door was opened. At 10:00 AM on 07/11/18, investigation found Resident #34 had two (2) secure care alarm devices - one device was on her ankle and one device attached to her wheelchair. The alarm system of the front door was tested on [DATE] at 10:05 AM, by the NHA and the Maintenance Supervisor (MS). When a secure care bracelet was held by the MS, within approximately two to three feet of the front door, the door locked. However, once the MS stepped back from the door, the door could be opened. When the door was held open by the surveyor, the MS was able to pass through the front doors, while holding the secure care bracelet, without the alarm sounding. The MS said the alarm system should always activate when any resident with a secure care system passed through open doors. At 11:05 AM on 07/12/18, the NHA said, As for the wander guard system we just had random checks in place that were not documented. It was just verbal saying the doors were checked. I have changed that now. 2. Review of the facility reports of elopement to the nursing home program Further investigation of the facility's reportable allegations of elopement to the nursing home program found another resident, Resident #58, (now discharged ) had exited the facility on 05/24/18. The facility's investigation found, (Name of resident) and another male resident were found taking a walk outside of the facility back by the employee smoking area. (Name of Resident) does not have capacity and currently has a secure care transmitter in place. (Name of Resident) exited the facility while the door was held open by another resident who is alert/oriented and does not have a secure care transmitter. No injury occurred to (Name of Resident) or the other Resident. (Name of resident) re-entered the building without difficulty or issue. Equipment will be tested . alert/oriented resident will be educated. The transmitter was tested and was working properly, according to the immediate action taken. At 10:32 AM on 07/11/18, the NHA said she did not know how staff tested the doors after the elopement on 05/24/18. She could not verify the door was tested after being opened. Observation with the NHA found a secure care system on the front door, the patio door, leading to the staff smoking area and the service entrance doorway. At 10:50 AM on 7/11/18, the NHA said she called the Secure Care Company. She said, It is a fluke and Secure Care is on the way. The NHA verified the Secure Care Alarm System was supposed to alarm even if the door was already opened when any resident wearing a secure care alarm passed through the open door. b) An immediate jeopardy was found as a result of the facility failing to do background checks on individuals used by the facility to provide direct care to residents and failing to implement its own policy. 1. LPN #64 A review of personnel files, on 07/11/18 at 03:00 PM, revealed the facility had employed agency staff, LPN #64 on 05/11/18. When the employee files were brought to the surveyor for review, the file for Employee LPN #64 was not included. When this omission was brought to the Administrator's attention on 07/11/18 at 3:06 PM, the Administrator stated, The employee's file is here in the facility and I was trying to find it. On 07/11/18 at 04:01 PM, Corporate RN #87 stated there was no employee file for LPN #64 at the facility. It was verified at that time that LPN #64 was currently on the schedule to work and had been working in the facility since 05/11/18. A review of the time record for LPN #64 on 07/11/18 at 04:02 PM, revealed the employee worked at the facility on the following dates: 05/11/18, 05/13/18, 05/17/18, 05/18/18, 05/21/18. 05/2218, 05/25/18, 05/26/18. 05/27/18, 05/31/18, 06/04/18, 06/05/18. 06/06/18, 06/10/18, 06/11/18, 06/14/18.06/15/18, 06/18/18, 06/19/18 ,06/22/18, 06/23/18, 06/24/18, 06/28/18, 06/29/18,07/04/18, 07/08/18, and 07/09/18. LPN #64 was scheduled to also work 07/11/18 from 6:45 PM-07:15 AM. 2. LPN #7 A review of personnel files on 07/11/18 at 03:00 PM, revealed the facility employed agency staff, LPN#7 on 06/25/18. The file did not contain documentation that LPN #7 had been screened by WV CARES system for background information. Additionally, LPN #7's LPN license was for a distant state, and there was no evidence of a current West Virginia licensure. An interview with the facility administrator on 07/11/18, at 03:06 PM, verified LPN #7 did not have a background check completed through WV CARES and had only the license from another state on file. Further interview on 07/11/18, at 04:01 PM with Corporate RN#87, revealed there was no background check completed on LPN#7 through WV CARES and they only had proof of a LPN license from another state. Employee LPN#7 was hired to work at the facility on 06/25/18. A review of the time records for dates worked were as follows: 06/25/18, 06/26/18, 06/27/18, 06/28/18, 07/02/18, 07/03/18, 07/04/18, 07/07/18, 07/08/18 and was working on the unit providing direct care when the deficient practice was discovered on 07/11/18. 3. A review of the facility's policy, OPS300 Abuse Prohibition included, The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. (Refer to Human Resources Policies and Procedures, Background Investigations policy.) 2.1 The Center will not employ or otherwise engage individuals who 2.1.1 Have been found guilty by a court of law of abuse, neglect, exploitation, misappropriation of property, or mistreatment; or 2.1.2 Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. 2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service will be reported to the state nurse aide registry or licensing authority; 2.1.3 Have had a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [REDACTED].>or misappropriation of resident property. c) Interview with the administrator At 11:05 a.m. on 07/12/18, the administrator said, The employee stuff just slipped through the cracks. The QA (quality assurance) committee talked about licensure, but not about the background checks. I will be adding that to the QA agenda. The administrator thought the Human Resources Manager was checking the employee files. As for the wander guard system we just had random checks in place that were not documented. It was just verbal saying the doors were checked. I have changed that now. The administrator said she was not sure how the exit doors with the alarm system were checked after the elopement in May. The elopement was discussed in the QA meeting but the functioning of the alarm system was never discussed. The administrator said this would now be reviewed in the QA meetings. d) Attendance at Meetings During an interview on 07/12/18 at 8:12 AM, the Administrator reviewed the sign-in sheets provided by the facility and agreed the minimum required personal were not in attendance. The facility, QI Signature Sheet, dated 08/26/17, did not have the Director of Nursing present. On 12/28/17, there was not a Director of Nursing or a Medical Director present. On 04/26/18, there was not a Medical Director present. | 2020-09-01 |
| 1609 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 880 | F | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy, record review, resident interview and staff interview the facility failed to implement infection control procedures to prevent the spread of disease and infection to the extent possible. Laundry Room staff were air-drying towels used in the kitchen in the soiled utility room. Resident #56 was not placed in contact isolation for 24 hours after treatment for [REDACTED].#52 was not placed in contact isolation as ordered by her physician for [MEDICAL CONDITION] (C diff) infection. These findings had the potential to affect all residents. Resident identifiers: #56 and #52. Facility census: 61. Findings included: a) Laundry An observation on 07/10/18 at 11:00 AM, with Housekeeping Supervisor (HS) #4 found towels tied in a knot on a rack between the two (2) washing machines in the soiled laundry room. When asked what that was between the two washers, she said, Those are the towels used in the kitchen. We were told it was a fire hazard to air dry them in a dryer. So that is why they air-dry them. A soiled laundry cart was pushed against the drying rack on which the kitchen towels were drying. After questioning the cleanliness of air-drying in the soiled laundry room, she agreed that it was not a good idea to have the kitchen towels dry in the soiled side of the laundry room. In an interview on 07/12/18 at 9:00 AM, the Administrator said she had no idea housekeeping was not using the dryer. Housekeeper Supervisor #4 said that she would move the drying rack to the clean side of the laundry room. She agreed it was not following infection protocol to dry them in the soiled room. b) Resident #56 Record review on 07/09/18 at 3:00 PM, found Resident #56 was admitted with lice. She was treated for [REDACTED]. During an interview on 07/10/18 at 12:00 PM, the Director of Nursing (DON) verified Resident #56, and three (3) other roommates were also treated for [REDACTED]. During an interview on 07/10/18 at 2:38 PM, the DON reported Resident #56 and the other three residents were not placed in Contact Isolation for 24 hours after treatment. The facility's procedure 'Pediculosis (Body, Head, Pubic lice)' Effective date 09/01/04 Revision date: 11/28/16, directed, 4.2. Use Contact Precautions until 24 hours after treatment was administered. c) Resident #52 Medical record review on 07/09/18, revealed Resident #52 had received medication for [MEDICAL CONDITION] and should be isolated by Contact Precautions. An interview, on 07/09/18, at 11:08 AM, with Resident #52, revealed that she was having problems with diarrhea. At that time, no isolation sign was observed on the resident's door indicating any precautions to use before entering the resident's room. An interview with the Administrator on 07/10/18, at 04:45 PM, verified that Resident #52 had been in isolation at the time the survey began, but was discontinued on 07/10/18. A review of the policy and procedure IC301, Contact Precautions revealed the facility was to Place a 'STOP,' Please see nurse before entering room sign on the door. Further interviews with the Administrator on 07/10/18 at 4:45 PM, verified there should have been a sign placed on the door indicating precautions were needed when entering the room. | 2020-09-01 |
| 1610 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 883 | E | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based medical record review, review of the Center for Disease Control and Prevention (CDC) recommendations, and staff interview, the facility failed to ensure all eligible residents received, or were voffered, pneumococcal vaccinations. This was evident for four (4) of the five (5) residents reviewed for immunization status. Residents identifiers: #3, #31, #37, and #34. Facility census: 61. Findings included: a) Resident #3 Immunization status for this resident was reviewed with the Director of Nursing (DoN) on 07/11/18 at 9:00 AM. This resident was admitted to the facility on [DATE]. Evidence revealed this resident received Prevnar13 (PCV13) on 08/09/15 with no evidence of receiving [MEDICATION NAME] 23 (PPSV23) one year later, as recommended the CDC. b) Resident #31 This resident entered the facility on 04/01/17. Review of medical records with the DoN revealed this resident's daughter reported the resident had received a pneumonia vaccine four (4) or five (5) years ago, but was not sure which one. No other information was obtained. The facility failed to consult with the resident's physician regarding administration of pneumococcal vaccines. c) Resident #37 Review of medical records with the DoN revealed this resident was admitted to the facility 01/11/17. The facility failed to obtain information regarding resident's pneumococcal vaccinations. The only documentation about pneumococcal vaccines was a discharge note from a local hospital with the admitted handwritten on the paper. d) Resident #34 The facility failed to provide this resident with recommended pneumococcal vaccinations in accordance with CDC recommendations. The DoN reviewed the resident's medical records and found a consent form dated 08/23/16 from the resident's daughter for the vaccine to be administered. Written on the form was, Received at another facility 9/1/15. There was no indication of which pneumonia vaccine was given and no record to indicate whether any pneumococcal vaccines were given at this facility. e) The DON acknowledged the facility was not ensuring residents received, or offered, pneumococcal vaccination as recommended by the CDC. d) DON agreed the facility was not following the CDC guidelines with regards to pneumococcal vaccinations. e) The facility's policy, IC601 Pneumococcal Vaccinations-Prevnar 13 (PCV13) or [MEDICATION NAME] (PPSV23), dated 11/28/17, stated the facility would provide the opportunity to receive the pneumococcal vaccine to all patients in adherence with current CDC recommendations. | 2020-09-01 |
| 1611 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 908 | D | 0 | 1 | 5JPY11 | Based on a random opportunity for discovery, observation and staff interview, found the facility failed to maintain all mechanical electrical in safe and operational condition. The air conditioner in Resident #37's room was turned off at the breaker box, which rendered it unusable. Additionally, the metal electric outlet box in which the air conditioner was plugged into, was lying on the floor. This was random opportunity for discovery. Resident identifier: #37. Facility census 61. Findings included: a) Resident #37 During an interview on 07/09/17 at 3:58 PM, the residents brother said that his brother received good care at the facility, but the only problem he had was that his room smelled so bad. He said in the past he had spoken to the administrator about the room being dirty and smelling countless times. He also was concerned about the facility turning off the air conditioner in the room so his brother could not control the temperature of his own room. He said was told that because his brother urinated in the air conditioner unit, they turned it off. He stated that did not address the problem with the odor. He said his brother now has a fungal infection on his body folds from not having air conditioning on the very hot days. During an interview on 07/10/18 at 8:36 AM, Nurse Aide (NA) #82 said the air conditioner/heater unit was working, but when she tried to turn it on, it would not come on. It was also noted at that time, that the air conditioner was plugged into an electrical box lying on the floor in brown stains that remained on the floor. During an interview on 07/10/18 at 8:37 AM, the Administrator said she was also unaware that his air conditioner was not working or that the outlet box the unit was plugged into was not mounted on the wall, but was lying on the floor. During an interview on 07/10/18 at 8:53 AM, Maintenance Supervisor (MS) # 18 said he was aware that this Resident's air conditioner unit was not working and had been off for one month or more. He stated he was afraid the resident would get electrocuted, so he turned the breaker off. He stated that he had a fan in his room and as far as he knew, the resident had not complained. He then agreed the resident did not have capacity to know to complain. During an interview on 07/10/18 at 2:04 PM, MS #18 reported a shield was placed on the air conditioner unit to prevent urine from going into the unit and power was restored in Resident #37's room. The metal electrical box was still lying on the floor which was pointed out again to MS#18. He said that was unaware of that and would mount the outlet box to the wall. | 2020-09-01 |
| 1772 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2018-07-12 | 655 | F | 0 | 1 | 3KXQ11 | Based upon record review, staff interview and resident interview, the facility failed to provide the resident or their representative with a written summary of the baseline care plan within 48 hours of admission. This was found for residents #80, #11, #32, #35, #15, #20, #37, and #3, and had the potential to affect all residents in the facility. Census: 30. Findings included: a) Resident #11 Resident #11 was admitted in the month of (MONTH) (YEAR). She is acting as her own responsible party. During an interview on 7/10/18 at 10:00 AM, Resident #11 was asked if the facility had met with her within forty-eight hours of her admission to discuss her care needs and plan the care and services to be provided during her stay, and the desired goals of those services. She said they had not. b) Resident #15 Resident #15 was admitted to the facility in the month of (MONTH) (YEAR). She is acting as her own responsible party. Resident #15 was interviewed on 7/10/18 at 9:19 AM. She was asked if her care needs and the facility's plan to meet them were discussed within 48 hours of her admission, and if she was provided with a written summary of the discussion. She said could not recall discussing or receiving any written copy of a plan regarding her care needs, the care and services to be provided during her stay, or the desired goals of those services. c) Resident #32 Resident #32 was interviewed on 7/10/18 at 9:36 AM. She said she could not recall discussing or receiving any written copy of a plan regarding her care needs, the care and services to be provided during her stay, or the desired goals of those services. d) Resident #35 Resident #35 was interviewed on 7/10/18 at 10:15 AM, and he also said he could not recall discussing or receiving any written copy of a plan regarding his care needs, the care and services to be provided during his stay, or the desired goals of those services. e) Staff Interview The Director of Nursing, Registered Nurse #39, was interviewed on 7/10/18 at 3:30 PM. She said the facility does not furnish written copies of the baseline care plan to the residents or their representatives. This was further confirmed during a brief interview with the Director of Nursing #39, facility Administrator #22, and the Skilled Services Director, Registered Nurse #19 on 7/10/18 at 3:40 PM. e) Additionally the other sampled residents (#80, #20, #37, and #3) reviewed for baseline care plans had been given a written summary of their baseline care plans, and based upon the staff interviews, this would be the case for all current residents. | 2020-09-01 |
| 1773 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2018-07-12 | 657 | D | 0 | 1 | 3KXQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F657 S/S=D Based upon record review, staff interview, and resident interview, the facility failed to develop and implement person-centered comprehensive care plans that were sufficiently individualized to ensure all staff were equipped to provide effective care to each resident based upon their specific needs and circumstances. This was found for the two (2) residents who had been in the facility long enough to have a comprehensive care plan completed. Resident Identifiers: #11 and #15. Facility census: 30. Findings include: a) Resident #11 is [AGE] years of age. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She is acting as her own responsible party. Resident #11 was interviewed on 7/10/18 at 10:00 AM. She said that she was admitted to the acute care hospital initially due to severe pain in her neck and the back of her head. She said the pain caused her to clench her teeth so hard she fractured one of her teeth. She said while she was in the hospital, her bowel obstruction happened and she had to have emergency surgery. She expressed her concerns were that her fractured tooth be attended to, that she had a new [MEDICAL CONDITION] and was apprehensive about being able to care for it herself, and her extensive surgical wound that required sponges to be inserted into her abdomen. She said she was concerned that she would not be able to get enough physical exercise to prevent decline because of the extent of her abdominal surgery. She said she was afraid to eat because the other day her [MEDICAL CONDITION] bag filled up and burst all over her. Resident #11 was one of two residents with a stay of sufficient duration to have a comprehensive care plan completed. Review of the comprehensive care plan found no mention of her tooth, her [MEDICAL CONDITION], or the specific issues regarding her extensive surgical wound. A copy of the comprehensive care plan including signatures was requested and provided by the Director of Nursing, #39, on 7/11/18 at 8:00 AM. The resident had signed the comprehensive care plan, but there were no dates for any of the signatures. It was noted the care plan had been printed on 6/24/18. An interview was conducted with Skilled Services Director, Registered Nurse #19, on 7/11/18 at 8:15 AM. She said the baseline care plans were completed by the Nurses during the admission process. She confirmed residents were not being given a written summary of the baseline care plan. She was asked when the care plan conference had been held with resident #11. She said it was done on 6/24/18. After a discussion of the contents of the care plan, she agreed there was no person centered, individualized information. She said she did not include the [MEDICAL CONDITION], and was unaware of the broken tooth. b) Resident #15 is [AGE] years of age. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She is acting as her own responsible party. Resident #15 was one of two residents with a stay of sufficient duration to have a comprehensive care plan completed. A copy of the comprehensive care plan including signatures was requested and provided by the Skilled services Director, Registered Nurse #19, on 7/11/18 at 11:00 AM. The resident had signed the comprehensive care plan, but there were no dates for any of the signatures. It was noted the care plan had been printed on 7/10/18. An interview was conducted with Skilled Services Director, Registered Nurse #19, on 7/11/18 at 11:15 AM. She was asked when the care plan conference had been held with resident #11. She said it was done on 7/10/18. After a discussion of the contents of the care plan, she agreed there was no person centered, individualized information. She said one part of the care plan, related to chronic confusion, was actually not intended to be care planned for resident #15, and was evidently pulled to the care plan by the computer software. She agreed the care plan contained no information about the fracture of multiple pubic rami with laminectomy. c) The investigation found the two (2) available comprehensive care plans were not sufficiently individualized to ensure all staff were equipped to provide effective care to each resident based upon their specific needs and circumstances. | 2020-09-01 |
| 1774 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2018-07-12 | 756 | F | 0 | 1 | 3KXQ11 | Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the monthly medication regimen review process. This practice has the potential to affect all. Facility census: 30. Findings included: a) The facility policy titled 9.1 Medication Regimen Review with an effective date of 11/28/16, states the Medication Regimen Review (MRR) of each resident must be reviewed at least once a month by a licensed pharmacist. Section 6 of the procedure states: The pharmacist will address copies of residents' MRRs to the Director of Nursing and/or attending physician and to the Medical Director . Section 7 states: Facility should encourage Physician/Prescriber or other responsible parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR . Section 11 states: The attending physician should address the consultant pharmacist's recommendations no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. **Except for the identified urgent irregularities, the policy lacks time frames for the various steps in the process. During an interview with Employee #72, Pharmacist on 07/11/18 at 2:45 PM, reported there was no policy with time frames for pharmacy review. | 2020-09-01 |
| 3686 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 558 | D | 0 | 1 | SQBP11 | Based on observation, resident interview, and staff interview, the facility failed to provide services with reasonable accommodation for residents. Resident #21 and #323's over the bed light cords were not long enough to be easily reached by the residents. This practice affected two (2) of nineteen (19) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #21 and #323. Facility census: 72. Findings included: a) Resident #21 An observation of the Resident, on 07/10/18 at 10:30 AM, revealed the Resident's over the bed light cord was approximately four inches long. An interview with the Resident, on 07/10/18 at 10:35 AM, revealed the Resident could not reach the over the bed light cord while in bed. The Resident stated the light was hard to turn on and off with the short cord. The resident stated she had reported the light cord to multiple staff members. b) Resident #323 An observation of the Resident's room, on 07/10/18 at 1:45 PM, revealed the Resident's over the bed light cord was approximately four inches long. An interview with Licensed Practical Nurse (LPN) #140, on 07/10/18 at 1:55 PM, revealed the over the bed light cords were too short. The LPN stated he would ensure the light cords were reported to the supervisor so they could be fixed immediately. | 2020-09-01 |
| 3687 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 583 | D | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect the personal privacy of a resident including personal and health information. An unlocked computer monitor was left unattended on top of a medication cart revealing personal and medical information for a resident. This was a random observation. Resident identifier: #69. Facility census: 72. Findings included: a) Observation A random observation, on 07/10/18 from 9:30 AM to 9:35 AM, revealed Licensed Practical Nurse (LPN) #140 left the computer monitor open on top of the medication cart for Resident #69. The computer monitor was left unattended in the hallway while the LPN went into a resident's room. The computer contained the following information: -Resident name -Date of birth -Physician -Medications -allergies [REDACTED]. b) Interviews An interview with LPN #140, on 07/11/18 at 9:35 AM, revealed he should not have left any patient information viewable on top of the medication cart while unattended. The LPN stated he usually covers the computer monitor while being away from the medication cart. An interview with the First Floor C Hall Unit Manager, on 07/11/18 at 9:40 AM, revealed the LPN should have covered the computer monitor before leaving it unattended. | 2020-09-01 |
| 3688 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 584 | E | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide maintenance services for six (6) of sixty (60) rooms observed during the Long Term Care Survey Process (LTCSP). The issues identified included resident's rooms and bathrooms with scratched walls, missing paint, damaged cabinets, dirty light fixtures, cracked floor tiles, a dirty vent, broken window screens, and rusted ceiling tiles . Room identifiers: #100, #103, #112, #215, #300, and #301. Facility census: 72. Findings included: a) Observations The following observations were made on 07/09/18, 07/10/18 and 07/11/18 during the LTCSP: -room [ROOM NUMBER]-The bathroom wall was scraped with missing paint The bathroom light was dirty. -room [ROOM NUMBER]-The bathroom wall had missing paint with scratches. The floor tiles by the bed were cracked. The clothing cabinet was missing chunks in several places. -room [ROOM NUMBER]-The bathroom light was dirty. The bathroom vent was filled with dust. The bathroom floor tiles were stained. The bathroom walls were missing paint. The ceiling tiles in the room were rusted. -room [ROOM NUMBER]-The wall behind the bed was missing paint. -room [ROOM NUMBER]-The window in the bathroom had a broken screen. -room [ROOM NUMBER]-The window in the room had a broken screen. b) Interview An interview with the Administrator, on 07/11/18 at 3:15 PM, revealed the nursing managers do daily room rounds looking for maintenance issues. The Administrator stated any issues found are put on a work order for the maintenance department. The Administrator stated the Maintenance Director does weekly rounds on the rooms as well as addresses maintenance requests from the staff. The Administrator stated since the building is so old it is impossible to keep up with all the maintenance issues. | 2020-09-01 |
| 3689 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 600 | D | 1 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of allegations reported to the State and the facility's investigation findings, resident interview, staff interview and medical record review, the facility failed to protect a resident's right to be free from abuse. The facility failed to recognize and address abuse. This was true for one (1) of one (1) resident reviewed for abuse during the Long-Term Care Survey Process (LTCSP) and investigation of complaint # . This practice had the potential to affect more than a limited number of residents. Resident identifier: #4. Facility Census: 72. Findings included: An interview with Resident #4, on 07/09/18 at 3:23 PM, revealed the resident said the staff did talk mean to her sometimes. When asked if she told anyone, she said she had reported things to the administrator and nurses, but nothing is ever done. Resident #4 stated, Sometimes staff will say that I lied about it. When the resident was asked how this made her feel she replied, It hurts my feelings, sometimes I go to my room and cry. When asked which staff was mean to her she said, Not everyone, a few of the aides but would not give this surveyor any names. During the interview the resident spoke slowly in a low raspy voice, taking time to form her words. At times the resident had difficulty forming her words. Resident #4 communicated with this surveyor mostly by writing notes on a legal pad paper with a pencil, that she had in bed beside her, in answer to the surveyor's questions. The resident also made yes or no gestures by nodding her head. Review of the resident's last quarterly minimum data set (MDS) with an assessment reference date (ARD) 03/28/18, on 07/10/18 at 03:00 PM, revealed the resident has adequate hearing and vision, unclear speech, and sometimes makes herself understood and has ability to understand others. Brief Interview for Mental Status (BIMs) score is fifteen (15) indicating resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. On 07/11/18 at 11:20 AM, review of complaint, concerns, and reportable incidents revealed an incident occurring on 2/09/18 concerning a staff member (Staff #74) reporting another staff member, healthcare service worker also known as a nursing aide (HSW#59), was rude and very hateful with Resident #4. The allegation stated that HSW#59 told Resident #4 that she (HSW#59) could not understand her (Resident #4) and if she was not going to put it on paper just go back to her room. HSW#59 was reported to have been pointing and shaking her finger at the resident while saying this to the resident. This allegation was unsubstantiated by the facility. The five (5) day follow up, also date 02/09/18, indicated the allegation was unsubstantiated. The investigative report indicated the reason as to why the allegation was unsubstantiated was due to Staff #74 (staff that reported the incident) changed her story from HSW#59 pointing and shaking her finger at the resident to pointing her finger as if to direct her (Resident #4) to go back to her room, if she was not going to tell them what she wanted. The investigative narrative report completed by Social Service Supervisor, SW#10, stated Resident #4 has a [DIAGNOSES REDACTED]. HSW#59 denied pointing or shaking her finger at the resident but did tell her to go back to her room or down the hall if she was not going to write down what she needed. HSW#59 was re-educated on tone of voice and how others perceive her. Review of an investigation witness statement dated 02/09/18, by Registered Nurse (RN), RN#60, revealed RN#60 was at the nurse's station when the alleged incident occurred. RN#60 stated, I know that they (HSW#59 and Resident #4) were arguing but I never really knew what it was about. RN#60 stated, HSW#59 told her (Resident #4) that she had already been down there (resident's room) and she couldn't understand what she (Resident #4) was wanting and that is about all I heard. RN#60 did not observe any finger pointing or the resident flipping HSW#59 off, because she stated I was just documenting and that was the reason that I probably did not see what was going on in the hall. RN#60 was new to the floor and was not familiar with the resident or HSW at that time. According to RN#60 and HSW#59 investigation witness statement, HSW#59 was argumentative with the resident. Review of an investigation witness statement dated 02/09/18, by Staff #74 revealed Social Service Supervisor, SW#10, interviewed Staff #74 a little while after the incident occurred. Staff #74 stated, Yes, she (Resident#4) came to the desk and was talking to the nurse at the desk. HSW#59 got involved telling her (Resident#4) that if she couldn't write it down she didn't need to be up there (nurse station) and she could go back to her room, very rude and very hateful like to her. When she (Resident#4) turned around to go back to her room Resident #4 was kind of tearful. When asked what the resident was doing while at the nurse station, Staff #74 replied she was just standing there looking and she started to talk. We all know she (Resident#4) is hard to understand, and that's when HSW#59 turned around and told her (Resident#4) if she couldn't write it down she did not need to be up there (nurse station) and told her to go back to her room. During the interview Staff #74 denied seeing the resident flip HSW#59 off and stated HSW#59 pointed her finger like just go back to your room. When asked during the interview to clarify whether HSW#59 was pointing at the resident or toward the resident's room, Staff #74 clarified it was kind of like just go back to your room. Staff #74 during the interview stated, It was very hateful, and I wouldn't talk to somebody like that especially a resident. Staff #74 reported as the resident was leaving, the resident was seen to be teary eyed, and Staff #74 thought it was from someone talking to her(Resident#4) like that. The administrator stated, So you made that assumption, and then asked Staff #74 if she had seen the resident when she first approached the nurse station desk. Staff #74 said No. The administrator said, So it is possible that she could have approached the station and already been teary eyed. Staff #74 responded, Yes ma'am she could have been. The administrator said, Okay. Staff #74 then said, I won't say yes or no. I just know what I seen at the end. Staff #74 reported Resident#4 was tearful when she left the nurse's station, and thought it was from someone talking to her (Resident#4) like that. The facility thought Staff #74 only made an assumption, and it was possible that the resident was teary eyed before coming to the nurse station. Yet no one addressed it or tried to find out why the resident was even teary eyed at all, before or after coming to the nurse station. If she was teary eyed because she had a need earlier and still had the need and could not get staff to understand what she needed; so that they could provide the goods or services necessary to meet the need and attain or maintain the resident's well-being. Review of an investigation witness statement dated 02/09/18, by HSW#59, revealed healthcare worker had earlier that day been in the resident's room to answer her call light. HSW#59 asked the resident what she needed but the resident only grunted. HSW#59 stated I said well you need to get a piece of paper because I don't understand that and a pen and can you write that down for me? Looked at me and said if you're not going to tell me what's wrong or tell what you need then can you please turn out the call light and she (Resident #4) said no. And I said well I have to stay in here until the light is off. She didn't say anything else, she just kept grunting and I said can you please get a piece of paper and she did not do it. There was no mention that HSW#59 tried to provide paper and pencil to the resident so she could write down her needs or even asked another staff to go in and see why the resident rang the call light. During the facility's investigation, when HSW#59 was asked what happened when the resident came to the nurse's station, HSW#59 replied, She (Resident#4) came up to the nurse's station and I asked her what did she need? And she gave me the finger, and I told her I wasn't gay and not to be inviting herself to me because that is not something that she needs to be doing. The administrator asked, Why did you feel the need to add the part when she gave you the finger? HSW#59 replied, Cause I'm not gay, and you don't invite yourself on somebody, and she gave me the finger and I'm not gay and that's what I told her. The administrator replied, This is a resident, (name of HSW#59) so why not just ignore that. HSW#59 responded, I don't get it, I don't understand yall tell us don't talk to a resident like they are children, talk to them like they are adults. And if somebody, an adult wants to give me the finger, I would tell them I'm not gay. If it was a woman, don't invite yourself to me. That's what I would tell them. I didn't say anything wrong I was just telling the truth. The administrator replied, You might be telling the truth, but it's unnecessary. It's comments that don't even need to be made. She is a resident, you know she is resident and being a resident, she has some type of issues, so don't even go there. Review of HSW#59 investigation witness statement revealed HSW#59 stated, when the resident came to the nurse's station, RN#60 was trying to get the resident to tell her what she needed. HSW#59 indicated to RN#60 that unless Resident #4 wrote it down she could not be understood. HSW#59 stated, I said just tell her (Resident #4) get a piece of paper (name of RN#60) because you're not going to understand it. This comment had the potential to be hurtful and humiliating as the resident has mental capacity and the resident has difficulty verbalizing her needs due to a history of a stroke. HSW#59 also stated the resident did not go get or did not ask for piece of paper. Further review showed no evidence any attempts were ever made by staff to provide or attempt to provide the resident with a pen and paper so that the resident could write down her wants or needs while she was at the nurse's station, a method often used by the Resident #4 to communicate to make her wants and needs known. In HSW#59 investigation witness statement, HSW#59 stated, I never shook my hand in her face or nothing like that or said she (Resident #4) couldn't have a pen or paper because I recommend her (Resident #4) to have a pen and paper because you can't understand nothing she says until she gets mad. Yet there was no evidence that paper and pen was provided to the resident. Interview with the administrator, on 07/11/18 at 4:33 PM with all the surveyors present, revealed the reasons why the facility unsubstantiated the allegation, dated 02/09/18 regarding HSW#59 and Resident #4. The administrator said Staff #74 reported she thought HSW#59 was rude to Resident #4, but during the investigation Staff #74 changed her story therefore it was unsubstantiated. Review of investigation records showed no evidence that Staff #74 changed her statement about the fact that she thought HSW#59 spoke rude and hateful toward Resident #4, only whether HSW#59 pointed and shook her finger at Resident #4 or pointed her finger toward the resident's room indicating the resident needed to go there. The administrator after reviewing the record said, I feel that we did investigate it because interviews were done. We also told HSW#59 that was something that she should not be telling residents (referring to the comment made to Resident #4 by HSW#5 And she gave me the finger, and I told her I wasn't gay and not to be inviting herself to me because that is not something that she needs to be doing. The administrator said, It was not appropriate or necessary for her to say that. The administrator after answering surveyor inquiries, said she did not take the remark made by HSW#59, as an inappropriate sexual comment or as being abusive. The administrator said the resident never had a concern about it or said anything. The allegation was not initiated by the resident, but by Staff#74. The administrator said the only problem she could see was HSW#59 saying something to Resident#4 about being gay, and that was not appropriate, and we asked (name of) RN#80, Staff Development, to do some education with HSW#59. The administrator did not consider the comment as a type of abuse, just poor customer service. The administrator did not know if the resident felt abused because the resident didn't report it. When asked if the resident was interviewed during the investigation to see how she felt about the entire incident, the administrator said she did not know, but was pretty sure the social worker (SW#10) went into talk to the resident. The administrator said, HSW#59 (name of) is an excellent nurse aid delivering care and ADLs (activities of daily living) but she does have a mouth. HSW#59 was pulled off the floor immediately when the incident was reported, she was not suspended. The administrator said, she was told by the state to stop suspension and rectify the situation if they could. The administrator said she feels that they rectified the situation immediately. If Staff #74 had not changed her statement regarding HSW#59, HSW#59 would have been suspended. The administrator also stated, It's almost to the point that no one can provide care to Resident #4 (name of resident). HSW#59 (name of HSW) went into her room to try to help her, but Resident #4 (name of resident) wouldn't tell her that she wanted. HSW#59 wasn't assigned to care for her. The administrator revealed to the surveyors multiple incidents where Resident #4 was sending grievances into the state as an employee on employee forms, sending two (2) to three (3) letters of complaints, and calling the governor's office. The administrator said Resident #4 has a history of making false allegations against staff and not cooperating. An interview with SW#10, on 07/11/18 at 5:47 PM, revealed SW#10 did not discuss the incident with Resident #4. She was not aware of any staff discussing it with the resident. SW#10 said she did not investigate or assess how the resident felt about the incident or how it affected the resident because the allegation was unsubstantiated. SW#10 said, Another employee was the one that reported it, not the resident. SW#10 stated she did not consider it as any kind of abuse, even when HSW#59 told the resident that she (HSW#59) was not gay and for the resident not to be inviting herself to HSW#59. SW#10 did not think Resident #4 might consider the comment offensive and said, .that is just how that aid (HSW#59) talks. It was poor customer service. The resident did not bring it to us. If that resident has a problem she always brings it to us, so I did not do a follow up. SW#10 said, HSW#59 did say in her statement that she made the statement about the gay remark and Staff Development, RN#80 did education with HSW#59 on that. At 6:08 PM on 07/11/18, an interview with RN#80 revealed education was provided to HSW#59 on 04/04/18 concerning communication guidelines and combative aggressive behavior. When RN#80 was asked why the education was provided, RN#80 replied because HSW#59 was trying to redirect Resident #323 and she understood NA HSW#59 got loud and Resident #323 started calling HSW#59 names. HSW#59 brought Resident #323 down to talk to the administrator. HSW#59 was talked to about being professional. RN#80 was asked was there any other education given, in February, to HSW#59 concerning comments made to Resident #4. RN#80 said this is the education I did for HSW#59 and gave the surveyor a copy of the training on 04/04/18 concerning communication guidelines and combative aggressive behavior. On 07/12/18 at 8:45 AM, random interviews with staff working on the floor that the incident occurred revealed Staff #23, Staff #74, and RN#150 had mandatory abuse training timely, was knowledgeable about the different types of abuse, and could give examples of the different types. Staff #23, Staff #74, and RN#150 was able to verbalize what to do if she saw abuse and who to report to. Staff #23 and RN#150 denied seeing any abuse in the facility. An interview with Staff #74, on 07/12/18 at 09:57 AM, revealed when asked if she had ever observed a situation concerning abuse. Staff #74 replied, Yes. When asked what she did about it. Staff #74 replied, I reported it. When asked what she reported, Staff #74 said, I reported (name of worker) HSW#59 was very rude and raised her voice to (name of Resident) Resident#4 and had (name of Resident) Resident#4 in tears. I don't like to see our residents talked down to. When asked what was done about it, Staff #74 said she did not know. When asked was there an investigation, Staff #74 said, Yes, but I don't know what happened about it. According to the Centers for Medicare & Medicaid Services (CMS), as of 11/07/17, Abuse, is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as defined at 483.5 and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Based on review of the facility's investigation the surveyors felt the allegation should have been substantiated not unsubstantiated. The surveyors felt that during the facility's investigation other issues and concerns were revealed and the facility failed to identify and/or address them. The administrator said Staff #74 reported she thought HSW#59 was rude to Resident #4, and during the investigation Staff #74 changed her story therefore it was unsubstantiated. Yet review of investigation records saw no evidence that Staff #74 changed her statement about the fact that she thought HSW#59 spoke rude and hateful toward Resident #4, and that the resident left the nurse station tearful. The facility's investigation focused on whether Staff #74 changed her story concerning HSW#59 pointing as to direct Resident #4 to go back to her room or pointing or shaking her finger at a resident. During the facility's investigation no one investigated or assessed how the resident felt about the incident or how it affected the resident. No resident interview or follow up was completed. The facility's investigation findings included; HSW#59 was argumentative with Resident #4; HSW#59 spoke rude and very hateful to the Resident #4; instead of letting the resident try to talk, HCW#59's told a nurse to get paper and pen for the resident to write it down because the nurse was not going to understand it, this was said in front of the resident and other staff and had the potential to be offensive and humiliating to the resident, and the resident was reported being seen tearful; there was no evidence that staff assisted the Resident #4 with paper and pen so she could write down and communicate her need. Writing was a common method used by the resident to communicate; HCW#59 inappropriately said to the resident, that she (HCW#59) was not 'gay' and for the resident to not be inviting herself to HCW#59. Insinuating the resident was coming on to her (HCW#59) which could also be considered offensive and humiliating and the resident was reported being seen tearful; and the resident was observed tearful and no one checked to see why. The facility after completing their investigation did recognize the need to re-educate HCW#59 on tone of voice and how others perceive her. who has difficulty speaking due to a stroke with [MEDICAL CONDITION] and who is difficult to understand when she is attempting to speak. | 2020-09-01 |
| 3690 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 641 | D | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) for one (1) of nineteen (19) residents reviewed during the long-term care survey. Resident identifier: #35. Facility census: 72. Findings included: a) Resident #35 Resident #35 had an order for [REDACTED]. Rivaroxaban (Xarelto) is an anticoagulant medication. Resident #35's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 05/08/18, Section N, Medications, stated no anticoagulant medication had been received by the resident during the last seven (7) days. An interview was conducted on 07/10/18 with Registered Nurse (RN) #13, who performed MDS Assessments. RN #13 stated that Resident #35's MDS with ARD 05/08/18, Section N, Medications, was incorrect and should have stated the resident received seven (7) days of anticoagulant medication. | 2020-09-01 |
| 3691 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 656 | D | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans for two (2) of nineteen (19) residents reviewed during the long-term care survey. The facility failed to develop comprehensive care plans for Resident #47 in the area of anxiety and for Resident #4 in the area of communication. Resident identifiers: #47, #4. Facility census: 72. Findings included: a) Resident #47 Review of the medical record revealed Resident #47 had a history of [REDACTED]. Review of Resident #47's comprehensive care plan revealed the problem, Impaired decision making due to: [MEDICAL CONDITION] disorder, anxiety, and dementia. The goal was, Will make daily choices in care. The comprehensive care plan revealed no problem specifically related to anxiety and no goals related to anxiety. On 07/11/18 at 3:57 PM, Registered Nurse (RN) #13 was interviewed about a care plan focus of anxiety on Resident #47's comprehensive care plan. RN #13 stated the problem area Impaired decision making in Resident #47's care plan contained interventions applicable to anxiety. However, she agreed additional interventions such as medication administration would be implemented for anxiety and were not included in the care plan. RN #13 also agreed Resident #47's care plan did not contain a measurable goal specifically related to anxiety. b) Resident #4 An interview with Resident #4, on 07/09/18 at 03:23 PM, revealed the resident said her vocal cords were damaged from having a stroke. Resident #4 spoke slowly in a low raspy voice, taking time to form her words. At times the resident had difficulty forming her words and became frustrated. Resident #4 answered the surveyor's questions and communicated with this surveyor, mostly by writing notes with a pencil on legal pad paper. The pencil and legal pad paper was lying on the bed beside her at the time of the interview. The resident also gestured by nodding her head yes or no. Review of the resident's last quarterly minimum data set (MDS) with an assessment reference date (ARD) 03/28/18, on 07/10/18 at 03:00 PM, revealed the resident has adequate hearing and vision, unclear speech, and sometimes makes herself understood and has ability to understand others. Brief Interview for Mental Status (BIMs) score is fifteen (15) indicating resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. On 07/11/18 at 11:20 AM, review of a reportable incidents revealed an incident occurring on 2/09/18. The five (5) day follow up investigative narrative report completed by Social Service Supervisor, SW#10, stated Resident #4 has a [DIAGNOSES REDACTED]. An interview with Unit Manager Registered Nurse (RN#150), on 07/12/18 at 09:21 AM, revealed the resident is encouraged to slow her speech. RN#150 stated the resident writes notes a lot. RN#150 said, Some staff can't understand her, and I go in behind them and make sure her needs are being met. Review of care plan, on 07/11/18 at 10:00 AM and again on 07/12/18 at 09:28 AM, revealed no problem focus area concerning communications with the resident. Nowhere in the care plan could there be found any mention that the resident was hard to understand and often uses writing as a method to communicate. There were no interventions for staff to ensure the resident had access to paper and pen/pencil to ensure she could make her needs known. There were no interventions for staff to follow whenever they could not understand the resident. On 07/12/18 at 09:49 AM, interview with Minimum Data Set (MDS) Nurse (RN#13), who is also responsible for the development of care plans, revealed the following. RN #13 verified the resident's care plan had not been developed to include person centered interventions for Resident #4 to address methods of communication. Resident#4 due to her [DIAGNOSES REDACTED]. | 2020-09-01 |
| 3692 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 657 | D | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to revise a care plan in the care area of activities of daily living (ADL). This was true for one (1) of one (1) resident reviewed for ADLs during the Long-Term Care Survey Process (LTCSP). This practice had the potential to affect more than a limited number of residents. Resident identifier: #4. Facility Census: 72. Findings included: On 07/09/18 at 03:26 PM observation of resident revealed Resident#4 had greasy hair, body odor, and was wearing a dirty t-shirt stained with what appeared to be dried food. The resident said she did not get the help she needs to clean herself up. Review on, 07/10/18 at 03:00 PM, of a quarterly minimum data set (MDS) with an assessment reference date (ARD) 03/28/18 revealed the resident has unclear speech and sometimes makes herself understood. The resident has ability to understand others and her Brief Interview for Mental Status (BIMs) score is fifteen (15) indicating resident is cognitively intact. Resident #4 needs supervision with dressing and bathing and limited assistance with personal hygiene. The resident is frequently incontinent of bladder and always with bowel. Pertinent [DIAGNOSES REDACTED]. On 07/11/18 at 10:00 AM, review of records revealed resident was admitted to the facility on [DATE]. Review of care plan revealed a problem area, Resident has selfcare deficit; requires assist with ADLs. Resident has behaviors of asking staff to perform ADL tasks for her that she is capable of doing. Interventions initiated in (YEAR) and (YEAR) included; Encourage resident to exercise and walk as much as possible daily; TED hose .applied in morning remove at bedtime; Encourage good personal hygiene; Shower with Shampoo 2x weekly and prn; personal hygiene non shower days; denture care; nail care; shave axilla and legs prn; hair care daily; right side bed cane assist with mobility; encourage resident to be as independent as possible, Trapeze bar to bed to assist with turning; and no lifting heavy objects, restriction of 10 pounds. Review of record on 07/11/18 at 6:10 PM revealed a care conference was held on 07/11/18 at 12:17 PM. The Medical Director wanted to attend due to issue he wanted addressed and was present at the meeting. Among the issues addressed was resident's non-compliance with personal care. At the meeting the Medical Director wanted to see more cooperation from the resident in the issues mentioned at the meeting as the issues had been going on too long. The resident denied non-compliance with some issues including taking showers and attending to her personal care. Before the Medical Director left the room, he wanted three (3) specific issues monitored/documented for the next two (2) weeks. The third issue was allowing staff to assist her with daily personal care. i.e., showers, clean clothing, hair shampoo. An interview with Unit Manager Registered Nurse (RN#150), on 07/12/18 at 09:30 AM, revealed RN#150 was hired in (MONTH) of this year. RN#150 said ever since she has been here the resident was not compliant with activity of daily living (ADL) care. I was told it had been going on for a while before I came, and it is an ongoing issue. RN#150 was not aware of the resident asking staff to perform ADL tasks for her that she is capable of doing for herself. RN#150 said she must go in frequently to encourage the resident to do ADLs. During the interview HSW#22 came to the nurse's station to ask for assistance from RN#150 to get Resident #4 to take a shower. On 07/12/18 at 09:49 AM, care plan was reviewed with Minimum Data Set (MDS) Nurse (RN#13), who is also responsible for the development of care plans. Review of care plan with RN#13 revealed, RN#13 confirmed care plan needed to be revised in the area of ADLs, and should have already been revised with some new person-centered interventions for the resident's on-going and current non-compliance with ADLs. | 2020-09-01 |
| 3693 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 684 | E | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for one (1) of nineteen (19) residents reviewed during the long-term care survey. The facility failed to follow the physician's orders [REDACTED].#47. Resident identifier: #47. Facility census: 72. Findings included: a) Resident #47 Resident #47 had a [DIAGNOSES REDACTED]. She was prescribed pain medication, [MEDICATION NAME] 5 milligrams (mg)/[MEDICATION NAME] 235 mg, three times a day. She also had an order for [REDACTED]. Review of Resident #47's medical records for the week of 07/04/18 through 07/10/18 revealed Pain Management Logs completed on the following dates at the following times: - 07/04/18 at 12:04 AM - 07/05/18 at 2:01 AM - 07/06/18 at 2:04 AM - 07/06/18 at 4:52 PM - 07/07/18 at 3:11 AM - 07/07/18 at 5:04 PM - 07/08/18 at 2:27 AM - 07/08/18 at 7:00 PM - 07/09/18 at 2:50 AM - 07/10/18 at 1:51 AM On 07/11/18 at 5:29 PM, an interview was conducted with the Director of Nursing (DoN) and with Registered Nurse (RN) #150. The DoN and RN #150 agreed pain management logs were not completed every shift for Resident #47. They stated pain assessments may have been documented elsewhere. Untimed shift reports were provided by the DoN and revealed the following information regarding Resident #47's pain: - 07/05/18: Denies any pain - 07/07/18: No complaints of pain - 07/09/18: No complaints of pain - 07/10/18: No complaints of pain However, medical records documenting pain assessments performed every shift as ordered by the physician were not provided. No further documentation was provided through the end of the survey. | 2020-09-01 |
| 3694 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 689 | E | 0 | 1 | SQBP11 | Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. A medication cart was unlocked and accessible to anyone. This practice had the potential to affect more than a limited number of residents. Facility census: 72. Findings included: a) Observation A random observation of the First Floor C Hall, on 07/10/18 at 9:30 AM, revealed a medication cart was unlocked while in the hallway. The cart was unlocked, unattended, and out of sight of any staff from 9:30 AM until 9:35 AM. The cart contained all the medications for the C Hall residents. b) Interview An interview with Licensed Practical Nurse (LPN) #140, on 07/10/18 at 9:30 AM, revealed the medication cart should always be locked when not in sight of the nurse. | 2020-09-01 |
| 3695 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 880 | E | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and State Operations Manual review, the facility failed to ensure an effective infection control program to the extent possible over which it had control. During medication pass observation, a nurse laid a medication box directly onto a resident's bedside table with no barrier to protect it from potentially picking up organisms which could be brought back to the medication cart. During observation of a fingerstick blood glucose test to check the blood sugar level of two (2) residents, the nurse laid the commonly shared blood glucose machine directly onto objects in the residents' rooms with no barrier to protect it from potentially picking up organisms. Also, the nurse cleaned the glucose machine with 70% alcohol between patient uses, although 70% [MEDICATION NAME] (alcohol) solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens according to the Federal Drug Administration (FDA) . The facility's policy directed staff to follow manufacturer's guidelines to clean the commonly shared blood glucose machines. The manufacturer's guidelines were vague on how to clean the blood glucose machines between multiple patient uses. These practices had the potential to affect more than a limited number of residents. Resident identifiers: #57, #25, #15. Facility census: 72. Findings included: a) Resident #57 During observation of a medication administration on 07/10/18 at 8:39 a.m., registered nurse Employee #60 (E#60) removed a box from the medication cart which contained a [MEDICATION NAME] hand-held inhaler. She then removed the inhaler from its box, and laid the now empty box directly onto the resident's bedside table. After the resident used the inhaler, E#60 then placed the inhaler back into its box. After E#60 washed her hands, she then picked up the boxed inhaler from the resident's bedside table and carried it back to the medication cart where she placed the container on top of the medication cart. Upon inquiry as to whether she should have used some type of barrier to lay the box upon rather than setting it directly onto the resident's bedside table, she replied in the affirmative. She agreed that a barrier should have been placed, or else not lay the box down in the room. She said she would clean the outside of the box before returning it to the medication cart. An interview was conducted with the assistant director of nursing (ADON) on 07/11/18 at 5:00 p.m. She said there has been education for the staff related to having a clean surface barrier at the point of service. The director of nursing (DON) was informed on 07/11/18 at 5:45 p.m. of the lack of barrier when placing a medication box directly onto an object in the resident's room (bedside table). At 6:05 p.m. on 07/11/18 the DON provided a copy of their medication pass checklist they use when observing employees during medication pass. It included having a clean surface barrier. b) Resident #25 On 07/11/18 at 11:41 a.m. licensed nurse Employee #97 (E#97) performed a fingerstick blood glucose test on Resident #25. E#97 laid the blood glucose machine and a small bottle of test strips on the heater in the resident's room while the nurse washed hands. E#97 then picked up the blood glucose machine and the bottle of test strips and laid them on top of the medication cart. E#97 wiped the exterior of the blood glucose machine for a few seconds with a 70% alcohol swab at 11:43 a.m. c) Resident #15 At 11:45 a.m. on 07/11/18 licensed nurse Employee #97 (E#97) entered Resident #15's room to perform a fingerstick blood glucose test. E#97 placed a folded paper towel on the resident's bedside table, then placed the blood glucose machine and a small bottle of test strips onto the folded paper towel. After the blood test was completed, E#97 threw the paper towel into the trash can. E#97 then laid the blood glucose machine and the bottle of test strips on the heater in the resident's room while handwashing was performed. At approximately 11:47 a.m. E#97 wiped the exterior of the blood glucose machine for a few seconds with a swab of 70% alcohol. Upon inquiry, E#97 said they always use 70% alcohol to clean the blood glucose machines between patient uses. An interview was conducted with the assistant director of nursing (ADON) on 07/11/18 at 4:30 p.m. She confirmed that their blood glucose machines may be used for either personal or professional use, meaning that the same blood glucose machine can be commonly shared among patients. She said nursing staff use 70% alcohol to clean the blood glucose machines after each patient use per manufacturer's guidelines. During an interview with the director of nursing (DON) on 07/11/18 at 6:05 p.m., she provided a copy of the facility's policy on Blood Glucose Monitoring, with effective date May, (YEAR). Page 1, Section A number five (5) stated The glucometer will be cleaned per manufacturer's directions after each use. Section II page three (3) item number fifteen (15) stated Clean the glucometer after each use per manufacturer's directions before using on another resident. The DON on 07/11/18 at 6:05 p.m. provided a copy of the QUINTET (name brand of the facility's blood glucose machine) user's manual which directed on page forty-five (45) how to clean the machine. It stated, Clean the outside of the QUINTET blood glucose meter with a damp cloth and mild soap/detergent. Keep the test strip port from getting wet. If your Test Strip Port is stained with blood, control solution or any liquid, please use a dry tissue or alcohol swab to clean it up immediately. Do not use anything wet to clean. Perform a quality control test to ensure the QUINTET blood glucose meter is working properly. The DON on 07/11/18 at 6:05 p.m. also provided a (MONTH) 2010 summary sheet document she said she obtained from the infection control nurse titled ASCP's Summary of Glucometer Cleaning Guidelines - (MONTH) 2010. This summary sheet pertained to the subject of cleaning and disinfecting glucometers in the long term care setting. It stated (typed as written) Be sure you are familiar with which glucometer manufacturer(s) your facility(ies) use(s) and the cleaning procedures recommended by that manufacturer(s) (SEE CHART BELOW). However, there was no chart attached to this summary sheet. On 07/12/18 at 9:30 a.m. an interview was conducted with the ADON, and with infection control nurse Employee #55 (E#55). They were shown, and read, an excerpt from the State Operations Manual, with revision date 11/28/17, which contained guidance from the Food and Drug Administration (FDA) as follows: The disinfection solvent you choose should be effective [MEDICAL CONDITION](human immunodeficiency virus), [MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] (alcohol) solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens, and the use of bleach solutions may lead to physical degradation of your device. A list of EPS registered disinfectants can be found on (name of website). The excerpt went to to say (typed as written) healthcare personnel should consult with the manufacturers of blood glucose meters in use at their facilities to determine what products meeting the criteria specified by the FDA are compatible with their meter prior to using any EPA-registered disinfectant for disinfection purposes. If manufacturers are unable to provide this information then the meter should not be used for multiple patients. The infection control nurse said they were not aware of an update in the regulations. During exit on 07/12/18 shortly before 2:00 p.m., the administrator said they followed the Center for Disease Control and Prevention (CDC) guidelines of 70% alcohol to clean their blood glucose machines between patient uses. | 2020-09-01 |