cms_VI
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16 rows
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Suggested facets: inspection_date, scope_severity, eventid, inspection_date (date), filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 240 | K | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, medical record review, resident family interviews and staff interviews, it was determined that the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. Specifically, several residents are forced to live in bed in their rooms for three to four days each week due to the lack of a sufficient number of Geri-chairs and/or other assistive devices needed to accommodate them when out of bed. The facility implements a rotating schedule which allows on average, two residents to be out of bed in Geri Cairs on alternating days. Those residents who are gotten out of bed most frequently are those described by staff as physically most active or most cognitively intact. In effect, these residents are confined in their rooms in bed for a significant portion of every week. This is a quality of life issue with the potential to affect the resident's physical, emotional, and psycho-social well-being. The findings are: 1. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident is alert and cognitively intact. She has a history of uncontrolled blood glucose levels and a history of falls, with severe injury sustained in her room on 7/11/10 while attempting to self toilet. Observations conducted by the survey team reveal that this resident was left socially isolated and without adequate assistance from staff for 3 of 5 survey days. During a tour of Unit B conducted on 8/19/10, at 9:30 A.M. this resident was observed in her room, alone and in bed. At 10:45 A.M., the resident was observed to still remain in bed. At Approximately, 12:10 P.M., after completing the tour and while walking along the corridor of unit B in the direction of the Nursing station, the surveyor heard resident #1 calling for help. The resident was calling in a loud voice, help!, Help!, will somebody please help me. The surveyor observed that th… | 2017-01-01 |
| 2 | 2 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 281 | D | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Medication adminisrration Records and Physician orders, it was determined that the facility does not assure that medication orders are transcribed in an accurate manner to ensure the appropriate doseage of medications to reisidents: The Findings are: Following obeservation of a Medication Pass conducted on 8/20/10, When the surveyor reviewed Physician order [REDACTED]. 1. An physician's orders [REDACTED].M , However, it was transcribed on the Medication Administration record as 2 units of [MEDICATION NAME] subcutaneously in the P.M. According to interivews conducted with the Director of Nursing on 8/20/10, the medication was not given to the resident erroneously because the transcription error was discovered and corrected prior to administration to the resident. The Incident Report of the transcription error dated 6/10/10, reads, the error was discovered and corrected prior to administration to the patient. The Incident report specifies that the nurse making the incorrect documentation was notified and informed of her error and teaching re-inforced regarding the need to double check all medication prescriptions. 2. A resident was prescribed [MEDICATION NAME] 2mg on 7/9/10 by the Physician, however the medication order was transcribed as [MEDICATION NAME] 20mg. on the Medication administration record. During an interview conducted with the Director of Nursing on 8/20/10 regarding this error in transcription the surveyor was informed that the medication was not given as erroneously transcribed, but was discovered by a nurse prior to administering medications. An incident report dated 6/10/10, 7:A.M., written by the nurse finindg the transcription error and which documents this occurence reads: Medication [MEDICATION NAME] transcribed incorrectly on MARS. I found this on 6/10/20 at 7:30 A.M. [MEDICATION NAME] was ordered as 2mg, transcribed 20mg ; Corrected MAR immediately. Error was reviewed with Ms._______ (nurse) and … | 2017-01-01 |
| 3 | 3 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 309 | G | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of resident medical records and facility policy and procedures, it was determined that the facility failed to ensure that each resident received the necessary care and services to manage pain. The facility does not have a formal system in place for pain management. This was evident for 2 of 10 residents who were observed to not receive medication for pain prior to , during , or immediately following wound care. The Findings are: 1. Resident #1 is a [AGE] year old female with [DIAGNOSES REDACTED]. The resident had a fall on 7/11/10 which resulted in a right [MEDICAL CONDITION] and a Total Hip Replacement (Hemiarthroplasty). The resident has a history [MEDICAL CONDITION] the soles of her feet. Although [MEDICAL CONDITION] healed, the resident's nursing documentation indicates the resident continues to experience tenderness at the burn sites. On 08/23/2010 @ approximately 2:20 p.m., a dressing change of the residents right heel was observed. The nurse performing the dressing change, was observed to check the doctor's order, sanitize her hands and then gathered supplies. As the old dressing was being removed, the resident groaned audibly. She was heard to groan twice. The Nurse (RN) performing the dressing change, did not pause or stop the procedure. She did, however, acknowledge the resident's painful response by saying to her I am sorry honey and continued with the wound care. She did not stop to assess the severity of the resident's pain and she did not offer the resident pain medication. When the surveyor asked the RN if the resident had received pain medication prior to the dressing change she replied, I am not entirely sure she if she has pain medication ordered. An interview was conducted immediately following the dressing change with this nurse. The nurse was asked why she did not stop, assess or offer the resident pain medication when the resident clearly was experiencing pain. She replied, She o… | 2017-01-01 |
| 4 | 4 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 311 | D | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations , resident and staff interviews and review of the the resident's medical record, it was determined that the facility failed to ensure that a resident receives appropriate treatment and services to maintain or improve her abilities to achieve and maintain the resident's highest practicable outcome. The Findings are: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/20/10 at approximately 5 PM, upon approaching the resident ' s room, the surveyor heard resident #1 calling for help. On entering the resident ' s room, the surveyor observed the resident was sitting in bed, the side rails were up, and a bedside table was positioned across the bed. A food tray was on this table . The following items were on the food tray: a container of milk, a vegetable dish, juice, 8oz cup of hot coffee, bread, and approximately 3 large stuffed Ravioli pasta shells. The resident was attempting to feed herself. she was struggling to cut the Ravioli. She was experiencing difficulty getting the food from the plate to her mouth which resulted in it spilling on her lap and on the bed. An interview with the resident was conducted at the time of this observation. The resident shared with the surveyor, that it is difficult for her to get help from the staff. When asked about the meals at the facility, she replied, The food usually tastes good but it was hard today. She stated, It is a good thing you were here today, otherwise I would not get to eat; I would still be fighting with it. The surveyor noted that after the pasta was cut into pieces and placed in the spoon for the resident , and the resident was cued that the food was on the spoon, she was able to pick up the spoon and to feed herself. At the time of this observation the resident appeared to have a very good appetite and ate approximately 80% of her meal. An interview was conducted with a staff nurse (Registered Nurse) assigned to resident #1 immediately f… | 2017-01-01 |
| 5 | 5 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 323 | L | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, and staff interviews, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible, and each resident receives adequate supervision and assistive devices to prevent accidents . This finding incorporates both environmental and quality of care practice. The environmental finding has the potential to place all residents in the facility at risk and constitutes Immediate Jeopardy. The Findings are: 1. The facility is a 40 bed SNF/NF facility built on a mountain top. One wing of the facility lacks a safe means of egress for evacuating residents in an emergency. The exit doors leading from this wing open onto a steeply sloped incline with a narrow cemented walkway which runs alongside the mountain cliff. The walkway does not have protective rails or barriers of any kind. Any resident wandering in this area who has an unsteady gait or makes a misstep is at risk of falling off the mountain cliff. This walkway is easily accessed from two other exit doors. Additionally, the facility has a number of residents who were identified as wanderers. Several residents were observed to wander outside of the building unattended by staff on various days of the survey from 8/19 through 8/25/10. One resident was observed taking a walk unattended on 8/20/10, at approximately 2:00P.M., and one resident was observed to sit outside of one of the exit doors unattended at various times throughout the day on all survey days. Meetings were held with the Facility owner, the Chief executive Officer, the Administrator and Director of Nursing Services on 8/19/10 at 12:35P.M. to discuss the Immediate Jeopardy findings. The Owner immediately arranged to correct this problem. On 8/20/10 at 11:00A.M. a construction company was observed on site preparing the grounds for construction. The construction includes the following: 1. Construction of a safety concreted ramp leading from the exit… | 2017-01-01 |
| 6 | 6 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 431 | D | 0 | 1 | MZE911 | Based on observations and staff interviews conducted during a Direct Survey it was determined that the facility did not ensure safe and secure storage of narcotics and emergency drugs, including the appropriate disposition, of drugs. This had the potential to affect all residents on both nursing units. Findings include: On 08/19/10 during the tour of the medication room, in the presence of the Director of Nursing (DON), the facility 's emergency box was noted to be unlocked, but was checked as locked on the medication log. When asked about this discrepancy, the DON stated It is my fault; the box is usually checked at the start of the shift by the day nurse. I saw the check mark made by the nurse at the lock not present column but I crossed it out. She did not give an explanation for why she had done this. A review of the contents of the emergency box revealed discrepancies between what the box contained and what ws transcribed on the log sheet . The following discrepancies were observed for the following medications: [REDACTED] 1. Glucagon Injection: the Emergency Medication log lists 7 but only 4 were in the box. 2. Phenergan Suppository: the Emergency medication log listed 6, but none were in the box. 3. Benadryl 25 mgs PO tabs: a bottle of 10 tablets was in the box, but not listed on log. 4. Epinephrine: the Emergency medication log listed 3 but only 1 was in the box. During an on-the-spot interview, the DON acknowledged that the count and content of the box should reconcile. On 8/19/10 at 3:15 p.m., a review of the narcotics record revealed that the narcotic medication count did not reconcile. The findings included: 1. The balance listed on the record for Ativan 2mg/cc Intramuscular was 1.75cc , the actual balance was 9.75cc. The narcotic sheet did not have an amount entered in the area designated as amount received from pharmacy. During an on-the -spot interview, the nurse was asked to explain the discrepancy related to the Ativan , she replied I believe that the individual signing out the Ativan mistook the… | 2017-01-01 |
| 7 | 7 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 441 | L | 0 | 1 | MZE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations of the facility environment, observation of nursing practices including blood glucose monitoring practices, medication administration procedures, storage of biologicals, storage of patient care equipment and products, wound care treatments, as well as information revealed in resident and staff interviews, and facility policies and procedures, it was determined that the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The findings are pervasive and systemic and have the potential to affect all residents on many levels and constitutes Immediate Jeopardy. The Findings are: 1. During the general tour conducted of the facility on 8/19/10 the following was observed: a) A storage room, identified by nursing as the clean utility room contained several metal shelves. An old, dirty mattress was on the floor and propped against one of these shelves. According to the nurse accompanying the surveyor on tour, We sometimes have used that mattress for patients in the past. I don't know why it's in here or when it was last used. Several plastic expandable air mattresses were observed on the top shelf rack. One half of this shelf was labled Dirty Mattresses, the other half contained several mattresses which the nurse identified as clean. Another shelf contained several packages of adult Attends briefs. Two of the packages were opened and exposed to air, 10 individual briefs were not enclosed in packaging, but lay directly on the shelf. Dust was visible on this shelf. A large torn, plastic bag containing air mattresses was also observed on this shelf. A layer of dust was visible on the plastic bag. The mattresses were identified by the nurse as clean air mattresses. b) The medication room contained a refrigerator identified as the medication refrigerator. When inspected, the… | 2017-01-01 |
| 8 | 8 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 469 | E | 0 | 1 | MZE911 | Based upon observations conducted on 8/19/10, 8/20/10, 8/23/10, 8/24/10 and 8/25/10 of the facility environment including hallways, resident rooms, dining rooms and care equipment, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. The findings are: On all survey days 8/19/10 through 8/25/10, roaches were observed crawling along corridor floors on both unit A and Unit B, were observed crawling on the walls of the corridors of both units, were seen in resident rooms, were observed crawling along the Nursig stations and were seen crawling on a medication cart and the Medication administration Record during a medication pass observation. Additionally, 5 of 6 residents confirmed this pest problem during a group meeting held on 8/20/10 at 10:30 A.M. During an interview held with the Maintenance Director on 8/19/2010 regarding the roach sitings, the Director acknowledged the problem of roaches and explained that the facility uses the services of a Pest control company which comes into the facility to exterminate different areas of the building each month and sometimes more frequently. Maybe the insecticide they use isn't effective or maybe we need to try another company. On 8/19/2010 at 5:330 P.M., the Maintenance Director provided the Survey team with a proposed contract for pest control services obtained from a new company. | 2017-01-01 |
| 9 | 9 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2010-08-25 | 490 | L | 0 | 1 | MZE911 | Based upon the extent of non-compliance with Federal Regulations identified during the Re-Certification Survey conducted from 8/19/2010 through 8/25/2010 it was determined that the facility is not administered in a manner that enbles it to use its resources effectively and efficiently to attain or maintain the highest physical, mental and psychosocial well-being of each resident. The Findings are: Refer to: F240 F309 F311 F323 F431 F441 F469 NFPA 101 Life Safety Code Standards K038: J K050: D K062: D | 2017-01-01 |
| 10 | 10 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 226 | G | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility complaints and investigations, and resident and staff interviews, it was determined that the facility failed to protect 1 of 14 residents (Resident #7) from physical abuse inflicted by staff and that caused the resident to sustain an injury. The findings are: Resident #7 is a [AGE] year old female diagnosed with [REDACTED]. Nursing Monthly Summary Assessments dated 7/1/2013, 8/1/2013 and 9/1/2013 indicate the resident is alert but confused, speaks incoherently, and requires assistance with transfers. The resident is non-ambulatory and uses a wheelchair. A complaint investigation dated 8/28/2013 identifies the resident as a victim of physical abuse. During review of the resident's medical record a nursing note documented on Clinical Notes dated 8/22/2013 at 5:30 P.M. were observed to read: I was made aware of a small cut to the resident's forehead. The area was cleaned ad a bandage applied; Incident report written. A second entry written for 1-3:00 A.M., reads: Met resident in bed asleep .bandage to forehead, slight swelling noted. A review of an Incident Report dated 8/22 /2013 reveals the resident sustained [REDACTED]. The incident report provides the following description of occurrence: A fight between two employees; Resident # 7 was found with a small cut to the forehead. Area was cleaned and antibiotics applied and covered with a bandage. An investigative Report dated 8/28/2013 summarizes the incident as follows: On August 22, 2013, it was reported that there was an altercation between a CNA and a housekeeper which started as a result of a resident's family member asking to have some fruit placed in the refrigerator. According to witnesses of the incident, the CNA questioned whether or not the fruit was labeled. The housekeeper said yes, they were, and felt that the CNA was harassing her. According to the LPN Charge nurse, she overheard the housekeeper asking the CNA to excuse (move away from) beh… | 2017-01-01 |
| 11 | 11 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 241 | D | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview and record review, it was determined that the facility failed to maintain residents appearance in a manner that promotes their dignity. The findings are: Resident # 9 is a [AGE] year-old male diagnosed with [REDACTED]. Care Plans for Dementia, documented 7/2013, indicate the resident is Aphasic, cognitively impaired, hearing impaired and requires total care for all ADLs. On 9/9/2013, at 9:40 A.M., the resident was observed during the initial unit tour lying supine in bed. The door to the resident ' s room was open, his bedside curtain was not drawn, and the resident was uncovered. A bed sheet was hanging off of the foot of the bed and the resident ' s lower body was exposed. The resident was observed to wear a hospital type gown that was pulled up to his torso and he was wearing an adult diaper. The resident ' s feet were exposed and revealed extremely elongated, mycotic toenails. The resident's fingernails were also extremely elongated and mycotic. An interview was held immediately with the nurse accompanying the surveyor who stated the staff needs to check this resident more frequently to make sure he stays covered because he ' s very restless, he pulls his covers off a lot and he should not be exposed. When the nurse was asked about the condition of the resident's finger and toenails, she explained the cutting of residents' fingernails is the responsibility of the Nursing Director and the Doctor is responsible for cutting everyone's toenails. I don't know why they were not done. They should be cut every three months. On 9/9/2013 at 10:00 A.M., during the interview conducted with the Director of Nursing to discuss resident #9 ' s care, the Nursing Director explained the facility maintains a monthly list of residents who require fingernail and toenail cutting. Residents are scheduled each month, and after the list is completed, it is signed off by the doctor and by the charge nurse or by me to indicate the res… | 2017-01-01 |
| 12 | 12 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 244 | E | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, it was determined that the facility failed to actively respond to a grievance regarding delayed meals presented by the residents at a resident council meeting. This was identified during a group meeting for 5 of 5 alert and oriented residents from 2 of 2 nursing units. This deficient practice was evidenced by the following: In preparation for the Quality of Life Assessment Group Interview the resident council minutes were reviewed from January 2013 through July 2013 and revealed that the issue of a long wait time for meals distribution was discussed in May and June. A review of the facility's Resident Council Concern Sheet used to follow-up on grievances did not reveal that the facility had responded to the resident ' s complaint of late meal delivery for either May or June of 2013. Resident Grievance files dated 03/20/2013 contain a complaint that indicates Food trays come to the unit, but there is a long wait/lag time before the trays are distributed and then the food is cold. There were no attached comments to indicate that the facility had responded to this grievance. During a group meeting conducted on 09/10/13 at 10:30 a.m., when asked Do you receive your breakfast, lunch and dinner on time? Four of five residents stated most of the time it's late. When asked how long beyond the scheduled time do the meals arrive? Four of the five residents attending stated, at least 30 minutes from the scheduled meal time. They all concurred that this practice occurs for all three meals. One of the residents told the surveyor, I am a Diabetic and take Insulin so this is not good for me (referring to the late meal distribution). The surveyor reviewed the record of this resident (resident #1), which revealed that the resident is an Insulin Dependent Diabetic. It further revealed that this resident was recently re-admitted to the facility on [DATE] following an acute hospitalization stay and is documented to have exp… | 2017-01-01 |
| 13 | 13 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 250 | E | 0 | 1 | IBTI11 | Based on observation, interview and record review, it was determined that the facility failed to provide effective medically-related social services to assist residents to maintain their highest practicable physical, medical and psychosocial well-being. The findings are: A group meeting was held with alert and oriented residents on 9/10/2013 at 10:30 A.M. 5 of the 5 residents in attendance stated in response to questions about the social worker, that they did not know the name of the social worker employed by the facility. 4 residents stated they had never met or been visited by a social worker, and 4 of the 5 residents complained they had never received assistance from a social worker to resolve any social service needs. Each resident in the Group stated, whenever they needed help with a problem, they consulted the Activities Director. Resident #12 complained of requiring assistance with his immigration status. The resident stated he did not receive any money from any source because he was having problems with renewal of his green card. The resident stated, as a result, he has not had any money, not even one dollar of his own, to put into his pocket for the past three years. The resident stated he has requested help with this problem, but no one has helped him. One resident in the group, Resident # 13, complained of not receiving any money from any source for the past two years. The resident stated he had spoken to nursing staff about this problem and it still was not resolved. This resident stated he had not met with a social worker to discuss this issue. He stated he did not know there was a Social Worker in the facility. Resident #13 also complained of the lack of response to his request for discharge from the facility. The resident explained he needed to return to his home to help care for his ill brother. He stated that although he had shared this concern with staff, he had not received assistance from anyone to facilitate his discharge. The resident stated he has not been seen by a Social Worker to discuss… | 2017-01-01 |
| 14 | 14 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 312 | D | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficient practice was noted for one of 14 sampled residents. The findings are: Resident # 9 is a [AGE] year-old male diagnosed with [REDACTED]. Care Plans for Dementia, documented 7/2013, indicate the resident is Aphasic, cognitively impaired, hearing impaired and requires total care for all ADLs. On 9/9/2013, at 9:40 A.M., the resident was observed during the initial unit tour lying supine in bed. The door to the resident ' s room was open, his bedside curtain was not drawn, and the resident was uncovered. A bed sheet was hanging off of the foot of the bed and the resident ' s lower body was exposed. The resident was observed to wear a hospital type gown that was pulled up to his torso and he was wearing an adult diaper. The resident's feet were exposed and revealed extremely elongated, mycotic toenails. The resident's fingernails were also extremely elongated and mycotic. An interview was held immediately with the nurse accompanying the surveyor who stated the staff needs to check this resident more frequently to make sure he stays covered because he's very restless, he pulls his covers off a lot and he should not be exposed. When the nurse was asked about the condition of the resident's finger and toenails, she explained the cutting of residents fingernails is the responsibility of the Nursing Director and the Doctor is responsible for cutting everyone's toenails. I don't know why they were not done. They should be cut every three months. On 9/9/2013 at 10:00 A.M., during the interview conducted with the Director of Nursing to discuss resident #9 ' s care, the Nursing Director explained the facility maintains a monthly a list of residents who require fingernail an… | 2017-01-01 |
| 15 | 15 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 314 | G | 0 | 1 | IBTI11 | Based on observation, interview and record review, it was determined that the facility failed to ensure that a resident without pressure sores, received the necessary care and services to prevent the development of a pressure sore. This was found true for one of 14 residents reviewed. The findings are: During the initial tour, conducted 9/9/2013 at approximately 9:40 P.M. on Unit A, Resident # 9 was observed lying in bed in a supine position. The resident was uncovered, and his feet were exposed. The resident was observed to wear heel pressure relieving booties on both feet. The bootie on his right foot was partially off, not covering the right heel, and the Velcro straps of the bootie were pulled tightly around the anterior longitudinal arch of the resident's foot. The bootie straps were observed to cover an open wound. The nurse accompanying the surveyor was immediately interviewed and stated she thinks the wound developed from the pressure of the bootie straps being pulled too tightly over the resident's foot. The Nurse stated the wound began to develop about three weeks ago. A CNA, identified as a consistent care giver for Resident # 9 was interviewed 9/9/2013 at 9:55 a.m. in the hallway outside of the Resident ' s room. In response to questions about the development of the resident's wound, The CNA stated, the straps on the booties caused the sore because they were being pulled too tight. An interview was held with the Director of Nursing {DON} immediately following the initial tour. The DON described the residents wound as a pressure sore that developed over time and caused by the straps of the bootie being pulled too tightly across the resident's foot. The DON stated they were not treating the wound because there was no drainage. She stated she had not yet in-serviced her staff on the proper application of heel booties to prevent pressure sores from developing, but would do so right away. The DON stated she would have the doctor evaluate the wound to determine what treatment is necessary. | 2017-01-01 |
| 16 | 16 | SEA VIEW NURSING HOME | 485000 | 7500 BOLONGO BAY | ST THOMAS | VI | 802 | 2013-09-13 | 325 | D | 0 | 1 | IBTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to effectively monitor a resident's nutritional status in the presence of unplanned weight changes. This deficient practice was identified in 1 of 10 residents (Resident #1) reviewed for nutritional concerns. This was evidenced by the following: The resident's [DIAGNOSES REDACTED]. The Clinical records, identified the resident as alert and oriented x 3, and able to make needs known. Resident Assessment Instrument (RAI), dated 8/13/31, indicated the resident's weight as 143 pounds (lbs.) and had experienced no significant weight gain or loss. Review of the physician's orders [REDACTED]. In the Initial Nutritional Assessment, dated 8/6/13, the Registered Dietician documented the resident's weight as 143 lbs., requires partial assist with tray set-up, could feed self, and consuming 75% of meals; weight gain may be due to decrease activity since foot/leg problems. No significant nutritional risk. A review of the resident's monthly weights recorded in the unit's weight book indicates the following: Resident #1's weight was 143 pounds (lbs.) on 08/06/13. On 8/26/13, the resident's weight was recorded as 126 lbs., indicating a 17 lb. weight loss in 20 days. A re-weigh performed on 8/27/13, listed the weight as 126 lbs. There was no documented evidence that the physician was informed of the weight variance of 17 lbs. between 8/6/13 and 8/27/13. The Registered Dietician documented the resident's weight on a Dietary Progress Note dated 9/6/2013 as 125 lbs. and documented that the resident experienced a significant weight loss of 10 lbs. in a 30 day period, and 15 lbs. in a period of 180 days. Although the Registered Dietitian (RD) identified the resident's weight loss as unplanned, there was no documented evidence that the RD evaluated for factors contributing to the resident's weight loss. During an interview conducted on the afternoon of 9/11/13, the Registe… | 2017-01-01 |
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CREATE TABLE [cms_VI] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );